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

 
We decided that the Plan does not have to waive the copayments for the ambulance services and specialist 
office visit provided from October 9, 2022, to October 24, 2022. 
 
You asked the Plan to waive the copayments for the ambulance services and specialist office visit. You say that 
you want all these charges removed since they were the result of a previous procedure. 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 $250 
copayment for each one-way ambulance trip. Your contract with the Plan also clearly says that you must pay a $50 copayment for each specialist office visit. 
 
You have been asked to pay a $250 copayment for the ambulance services. This item/service falls within the 
ambulance services category. You also have been asked to pay a $50 for the specialist office visit. This 
item/service falls within the physician/practitioner services benefit category. You have been asked to pay a 
total of $300 ($250 copayment + $50 copayment = $300). 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 the ambulance services and specialist office visit provided from October 9, 2022, to October 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the breast cancer screenings provided on 
November 16, 2022. 
 
You asked the Plan to waive the coinsurance for the breast cancer screenings. You say that you were told the 
facility was in-network. 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 50% 
coinsurance for each out-of-network covered screening mammogram.  
 
You have been asked to pay $30.64 coinsurance, which is 50% of the allowed amount for the 3D mammogram 
($61.28 allowed amount x 50% = $30.64). You have also been asked to pay $77.28 coinsurance, which is 50% 
of the allowed amount for the mammogram ($154.56 allowed amount x 50% = $77.28). This item/service falls within the breast cancer screening 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 
the breast cancer screenings provided on November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vaginal dilator and supplies. 
 
You asked the Plan to pre-approve a vaginal dilator and supplies. You say that the items should be covered. 
The Plan denied your request. The Plan says this item is not listed in the OTC catalog. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a vaginal dilator and supplies have not been met. Specifically, this item is not listed in the Plan's 
OTC catalog. Therefore, we decided that the Plan does not have to pre-approve a vaginal dilator and supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for an 
IRF admission 
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive drug testing (80307) and definitive drug 
testing of 1-7 drug classes (G0480) provided June 16, 2022. 
 
You asked the Plan to pay for the presumptive drug testing and definitive drug testing of 1-7 drug classes. You 
say that the enrollee needed these services. The Plan denied your request. The Plan says there is no 
documentation specifying what drug level is being monitored. 
 
The Plan follows Medicare rules. Medicare rules say that drug testing is covered when the criteria in the rules 
section of this letter are met. 
 
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 the presumptive drug testing and definitive 
drug testing of 1-7 drug classes. Our reviewer says that the testing is not medically necessary. Our physician 
reviewer found that the enrollee does not meet the criteria of the LCD regarding quantitative testing. The 
testing was not medically reasonable and necessary. 
 
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 presumptive drug testing and definitive drug testing of 1-7 drug classes have 
not been met. Therefore, we decided that the Plan does not have to pay for the presumptive drug testing 
(80307) and definitive drug testing of 1-7 drug classes (G0480) provided June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you would like to appeal the denied utility 
benefit. The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the member does not use insulin with at least three daily injections and 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 
 
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 and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visual field test performed on 
December 20, 2022, and the eye imaging performed on December 29, 2022. 
 
You asked the Plan to waive the copayment for the visual field test and the imaging. You say that you cannot 
afford the copayment for these services. 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 $45 
copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye, and a $10 copayment per day for Medicare-covered x-rays. 
 
You have been asked to pay a $10 copayment for the visual field test because the Plan is only holding you 
responsible for this amount, which is less than the $45 copayment. This item/service falls within the vision care 
benefit category. You have also been asked to pay a $10 copayment for the imaging. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies 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 visual field test performed on December 20, 2022, and the eye 
imaging performed on December 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are not able to get what you need 
with your over-the-counter benefit. The Plan denied your request. The Plan says the requested supplies are not 
a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the skilled nursing facility care provided 
on September 1, 2022. 
 
You asked the Plan to waive the cost sharing for the skilled nursing facility care. You say that you think that 
you are being billed incorrectly. 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 after you meet the annual deductible, for in-network facility evaluation and management services, 
and all other inpatient care services. 
 You have been asked to pay a $786.19 coinsurance for the skilled nursing facility care because the Plan is only 
holding you responsible for this amount, which is less than the 20% coinsurance. This item/service falls within 
the inpatient stay: covered services received in a hospital or skilled nursing facility (SNF) during a non-covered 
inpatient stay 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 cost sharing for the skilled nursing facility 
care provided on September 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Intracept procedure (64628) provided on October 26, 
2022. 
 
You asked the Plan to pay for the Intracept procedure. You say that the claim should be paid. The Plan denied 
your request. The Plan says the Intracept procedure is considered unproven as its clinical value and 
effectiveness have not been demonstrated in the peer-reviewed literature. 
 
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 the Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the intracept procedure is experimental. More research is needed to show safety 
and efficacy of the procedure. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for the Intracept procedure (64628) provided on October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve an oxygen concentrator. You say that the item should be covered. The Plan 
denied your request. The Plan says Medicare does not cover oxygen equipment for travel. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve an oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the below knee prosthetic sockets (L5629 and L5647). 
 
You asked the Plan to pre-approve the below knee prosthetic sockets. You say that the items are medically 
necessary, The Plan denied your request. The Plan says the member was approved for a preparatory below knee 
prosthesis (L5530) on February 7th, 2023. Medicare guidelines say that when a preparatory below knee 
prosthesis is provided, codes L5629 and L5647 will be denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that when an initial below knee prosthesis (L5500) or 
a preparatory below knee prosthesis (L5510, L5520,L5530, L5540) is provided, prosthetic substitutions and/or 
additions of procedures and components are covered in accordance with the functional level assessment except 
for codes L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962, and L5980 which will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the below knee prosthetic sockets have not been met. Specifically, a preparatory below knee 
prosthesis has been approved making the below knee prosthetic sockets not medically reasonable or necessary. Therefore, we decided that the Plan does not have to pre-approve the below knee prosthetic sockets (L5629 and 
L5647).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is extremely weak and 
debilitated from the hospitalization and will need extensive therapy while continuing to receive acute care in 
the LTACH setting. The Plan denied your request. The Plan says 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 all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines, IRF care is not 
considered medically reasonable or necessary. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the inpatient care provided from October 17, 2022, to 
October 26, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were not admitted to the 
hospital on October 17, 2022. The Plan denied your request. The Plan says that the copayment was applied 
correctly. 
 
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 Explanation of Benefits (EOB) the Plan provided does not match the 
admission dates provided. Without the correct EOB we are unable to determine if the cost share was applied 
correctly. Therefore, we decided that the Plan has to waive the copayment for the inpatient care provided from 
October 17, 2022, to October 26, 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 cost sharing for the nivolumab injection provided on 
November 2, 2022. 
 
You asked the Plan to waive the cost sharing for the injection. You say that you would like the cost sharing to 
be lower. 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-covered chemotherapy drugs and other Medicare Part B-covered drugs. 
 
 You have been asked to pay a $1286.50 coinsurance for the injection because you met your out-of-pocket 
maximum partway through the processing of the claim. 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 cost sharing for the nivolumab 
injection provided on November 2, 2022.