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

 
We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided 
from October 8, 2021, to October 14, 2021. 
 
You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that you already paid 
the $1,750 copayment for your inpatient hospital stay and do not feel you should owe another copayment for 
same stay. 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 $350 
copayment per day for days 1 to 5 for each Medicare-covered hospital admission or stay.  
 
 
  You have been asked to pay a total copayment of $1,750 for days 1 to 5 of an inpatient rehabilitation stay 
($350 per day x 5 days = $1,750). 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 an inpatient rehabilitation stay provided from October 8, 
2021, to October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and destruction procedures provided on 
August 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and destruction procedures. 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 an office visit and destruction procedures provided 
on August 4, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for provided on June 2, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for a diagnostic mammogram and a diagnostic digital breast tomosynthesis. You say 
that these are Medicare covered services. The Plan denied your request. The Plan says the enrollee's primary 
care physician did not refer for the services and requires a prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 provided on June 2, 2022, by an out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mvasi. 
 
You asked the Plan to pre-approve Mvasi. You say that the records provided support the need for the requested 
drug. The Plan denied your request. The Plan says the requested drug is not supported for the enrollee's type of 
cancer. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Mvasi. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found there are no clinical notes for rationale 
or showing what regimen the enrollee is to receive. Use of Mvasi is not indicated for the enrollee by any of the 
compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Mvasi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Mvasi.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing visits provided from 
May 10, 2022, to May 31, 2022. 
 
You asked the Plan to waive the copayment for the skilled nursing visits. You say that you and the enrollee are 
on a fixed income and could not afford home health. 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 $0 copay per day for days 1 to 20 and a $188 copay per day for days 21 to 100 for Skilled Nursing 
Facility (SNF) care.  
 
 
 
 The enrollee has been asked to pay a $0 copay per day for days 1 to 20 and a $188 copay per day for days 21 to 
100 for the skilled nursing visits. This item/service falls within the Skilled Nursing Facility (SNF) 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 copayment for the skilled nursing visits 
provided from May 10, 2022, to May 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 12, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that these were medically necessary services. The 
Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
Therefore, the decision is upheld. 
 
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 home health services provided on January 12, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is needed due to the enrollee's worsening 
heart failure. The Plan denied your request. The Plan says there is not enough evidence showing CardioMEMS 
helps with health compared to standard treatments. 
 
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 pre-approve CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining the long-term clinical 
outcomes to establish the value of CardioMEMS in patient management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit on September 17, 2021. 
 
You asked the Plan to waive the deductible for office visit. You say that you want to appeal the amount being 
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. Your 
contract with the Plan says that there is a $350 deductible which applies to Physician/practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/practitioner 
services, including doctor's office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $350 deductible which applies to Physician/practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time 
office visit was received on September 17, 2021. Therefore, we decided that the Plan does not have to waive 
the deductible for office visit on September 17, 2021.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 be improving and should only require additional short term 
acute care services that can be safely administered at the current facility until more stable and appropriate for 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopic retrograde 
cholangiopancreatography (ERCP) provided on May 19, 2022. 
 
You asked the Plan to waive the copayment for the endoscopic retrograde cholangiopancreatography (ERCP). 
You say that you had a partial procedure the week before, and you shouldnt have to pay for this one. 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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $300 copayment for the endoscopic retrograde cholangiopancreatography 
(ERCP). This item/service 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 waive the copayment 
for the endoscopic retrograde cholangiopancreatography (ERCP) provided on May 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient hospital services (J2001, 
V2785, J7120, J2250) provided by an out-of-network provider on January 19, 2022. 
 
You asked the Plan to waive the coinsurance for the outpatient hospital services. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says this 
coinsurance 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 30% 
coinsurance for Outpatient hospital services.  
 
 
  You have been asked to pay a 30% coinsurance for the outpatient hospital services. This item/service falls 
within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
outpatient hospital services (J2001, V2785, J7120, J2250) provided by an out-of-network provider on January 
19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
May 6, 2022. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that the enrollee was 
misdiagnosed and did not need the ambulance transportation. You say that you feel the enrollee should not be 
responsible to pay for an ambulance ride that they did not need. 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 $250 copayment per one-way trip for each Medicare-covered ambulance service.  
 
The enrollee has been asked to pay a $250 copayment per one-way trip for ambulance transportation. This 
item/service falls within the Ambulance Services 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 copayment for an ambulance transportation provided on May 6, 2022.   
Your complaint about the enrollee being required to travel in an ambulance when it was not needed is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 19, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
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 visit provided on July 19, 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 a skilled nursing facility (SNF) stay 
provided from December 28, 2021, to January 28, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you do not believe that you should be 
responsible for this large copayment. You had met your out-of-pocket maximum already and should not owe 
this. The Plan denied your request. The Plan says this cost sharing was charged correctly. Because you were in 
the SNF from 2021 to 2022, your out-of-pocket maximum expense was reset. 
 
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 $100 
copay per day, per stay for days 21-100 for skilled nursing facility (SNF) care.  
 
You have been asked to pay a $1,200 for days 21-100 for a SNF stay ($100 x 12 = $1,200). 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 a skilled nursing facility (SNF) stay provided 
from December 28, 2021, to January 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that the enrollee has had multiple unexplained 
hypoglycemic events. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a 
therapeutic continuous glucose monitor. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve use of a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle sleeve (A4467). 
 
You asked the Plan to pre-approve an ankle sleeve. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that elastic or other fabric support garments (A4467 
(BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE)) with or without stays or panels do 
not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. Code A4467 is 
denied as noncovered (no Medicare benefit).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an ankle sleeve have not been met. Therefore, we decided that the Plan does not have to pre-
approve an ankle sleeve (A4467).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on August 09, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
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 lab testing provided on August 09, 2022, by an 
out-of-network (OON) provider.