Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
October 03, 2022. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you disagree with the 
copaymet. 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 $30 
copayment for physician/practitioner services/specialist telehealth. 
 
You have been asked to pay a $30 copayment for a specialist telehealth visit. This item/service falls within the 
physician/practitioner services/specialist telehealth 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 specialist telehealth visit provided on October 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 07, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
July 07, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wegovy. 
 
You asked the Plan to pre-approve Wegovy. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered 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 Wegovy.  
 
Benefits for Wegovy 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: Home Health
Decision: Favorable

 
We decided that the Plan has to waive the copayment for Home health (HH) Services (99328) provided on 
January 20, 2022. 
 
You asked the Plan to waive the copayment for the HH services. You say that the services should be covered as 
you disagree with the charges and have paid $0 for the same services in the past. The Plan denied your request. 
The Plan says that 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 enrollees must pay a $0 copayment for home health agency care.  
 
The Plan says you must pay a $30 copayment for the HH services. Based on the Plan contract, however, you 
cannot be asked to pay more than a $0 copayment for the HH services. Therefore, we decided that the Plan has 
to waive the copayment for Home health (HH) Services (99328) provided on January 20, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on January 7, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with coinsurance. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs. The total amount you 
are being asked to pay is $585.38 ($2,926.89 x 20% = $585.38). This item/service falls within the Medicare 
Part B prescription drugs 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 Medicare 
Part B prescription drugs provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on July 11, 2022. 
 
You asked the Plan to pay for a facility visit. You say that we depend on the facility staff to verify eligibility 
and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a facility visit provided 
on July 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM). 
 
You asked the Plan to pay for a continuous glucose monitor (CGM). You say that the services requested are 
medically necessary. The Plan denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have to 
pay for a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 07, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
June 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on September 01, 2022. 
 
You asked the Plan to pay for ophthalmological services. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ophthalmological 
services provided on September 01, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for Home Health (HH) Services provided from January 2, 2022, to January 
28, 2022. 
 
You asked the Plan to pay for the HH services. You say that the services should be covered as you disagree 
with the denial and the claim was filed timely. The Plan denied your request. The Plan says that the provider 
did not follow plan procedures. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the plan did not make reasonable and diligent efforts to forward us information 
proving that the claim was filed untimely. Therefore, we decided that the Plan has to pay for Home Health 
(HH) Services provided from January 2, 2022, to January 28, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bariatric surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the surgery. You say that your previous network provider was negligent 
with the care provided. The Plan denied your request. The Plan says an authorization is on file for 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 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 
bariatric surgery to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on July 14, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
care provided on July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on October 31, 
2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment provided on October 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says the enrollee does not have complex nursing or medical needs requiring a resource 
intensive inpatient hospital setting. 
 
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 that the enrollee does not need a physical medicine and rehabilitation physician's supervision three times a week in an IRF. There are no acute rehabilitation nursing needs identified or 
documented. The enrollee does not need intensive therapies consisting of at least three hours of therapy per day 
at least five days per week with multidisciplinary approach in an IRF. While the enrollee may benefit from 
physical therapy and occupational therapy, the enrollee's rehab needs can be provided in a lower intensity and 
alternate 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compressor device to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compressor device. You say that the enrollee's medical condition 
can benefit from use of this equipment. The Plan denied your request. The Plan says the service can be 
provided by an in-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 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 
pneumatic compressor device 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 pay for the dental services on November 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve specialist office visit. You say that you could not find an in-network 
provider to treat your condition. The Plan denied your request. The Plan says the service can be provided by an 
in-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 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 
specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network diagnostic orthopedic 
appointment provided on October 06, 2022. 
 
You asked the Plan to waive the coinsurance for an out-of-network diagnostic orthopedic appointment. You 
say that you did not have two of the procedures listed, and therefore feel you should not have to pay this 
coinsurance. 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 30% 
coinsurance for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 30% coinsurance for an out-of-network diagnostic orthopedic appointment. This 
item/service 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. You had a visit with an 
out-of-network specialist, resulting in a 30% coinsurance of $252.11. Therefore, we decided that the Plan does not have to waive the coinsurance for an out-of-network diagnostic orthopedic appointment provided on 
October 06, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99291 provided on August 12, 2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan did not provide enough evidence to support the denial of 
payment for procedure code 99291 based on Medicare criteria. Therefore, we decided that the Plan has to pay 
for procedure code 99291 provided on August 12, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on September 30, 2021. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
September 30, 2021.