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

 
We decided that the Plan does not have to pay for the office visit rendered on September 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician 
 
We looked at the file and Medicare rules. Billed procedure code 99204 (office visit) was billed on the same 
date of service by a physician in the same group practice as code 99236 (observation or inpatient hospital care, 
for the evaluation and management of a patient including admission and discharge on the same date). Code 99204 is not payable. Therefore, we decided that the Plan does not have to pay for the office visit rendered on 
September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 27, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nutrition therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the nutrition therapy visits. You say that you want to see this provider so 
you may continue to practice continuity of care. The Plan denied your request. The Plan says the provider is 
out-of-network. 
 
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 
nutrition therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to adjust the copayment from $25 to $15 for the office visit (99214) provided on 
November 17, 2021. 
 
You asked the Plan to adjust the copayment. The Plan denied your request. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan says the copayment has been applied correctly to the 
service 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 enrollees must pay a $15 copayment for each primary care physicians office 
visit for urgently needed services.  
 
The Plan says you must pay a $25 copayment for the office visit for urgently needed services provided by a 
specialist. Based on the Plan contract, however, you cannot be asked to pay more than a $15 copayment as the 
service in this case was rendered by a Family Nurse Practitioner, primary care provider type. Therefore, we 
decided that the Plan has to adjust the copayment from $25 to $15 for the office visit (99214) provided on 
November 17, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiology services (99204, 99306, 93000) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve cardiology services. You say that the enrollee believes he was misdiagnosed 
at the previous facility, and he has declined referral to these hospitals as he has lost faith in their ability to treat 
him. The Plan denied your request. The Plan says except for covered emergency services, all services must be 
provided by Plan providers. The Plan also says that this provider is not a participating provider with the Plan 
and the requested non-emergent service is available and can be provided by Plan providers.  
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 
cardiology services (99204, 99306, 93000) to be provided 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 Skilled Nursing facility (SNF) services 
provided from November 11, 2021, to November 17, 2021. 
 
You asked the Plan to waive the copayment for the SNF services. You say that the services should be covered. 
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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for days 1-20 of Skilled nursing facility (SNF) care.  
 
 
  You have been asked to pay a $20 copayment for 6 days of for the SNF care ($20 x 6 = $120). 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 Skilled Nursing facility (SNF) services provided from November 11, 
2021, to November 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
network facility from November 22, 2021, to November 24, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were never 
admitted as an inpatient. You say you were only under observation and not placed in a separate room. The Plan 
denied your request. The Plan says you have been asked to pay 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 $310 
copayment per day for days 1 to 5 for covered hospital care.  You have been asked to pay a $310 copayment per day for the inpatient hospital stay. ($320 x 2 = $620). The 
inpatient hospital stay falls within the Inpatient hospital care covered hospital care. benefit category. The 
medical record shows you were admitted as an inpatient. 
 
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 hospital stay provided by a network facility 
from November 22, 2021, to November 24, 2021. 
  
Your complaint about not receiving proper care 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a laboratory test provided on November 3, 
2021. 
 
You asked the Plan to waive the copayment for the laboratory test. You say that the services should be covered. 
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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $5 copayment for a laboratory test. Laboratory tests fall 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 a laboratory test provided on November 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Tacrolimus. 
 
You asked the Plan to pre-approve a tier exception for Tacrolimus. The Plan denied your request. The Plan 
says tiering exceptions are only available for drugs billed on the Part D. 
 
The Plan must follow Medicare rules. Medicare rules say that each Part D plan sponsor that provides 
prescription drug benefits for Part D drugs and manages this benefit through the use of a tiered formulary must 
establish and maintain reasonable and complete exceptions procedures subject to CMS approval for this type 
of coverage determination. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Tacrolimus have not been met. Specifically, tier exceptions are not available for Part B drugs. 
Therefore, we decided that the Plan does not have to pre-approve a tier exception for Tacrolimus.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra for the enrollee. 
 
You asked the Plan to pre-approve Actemra. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the member has not tried and failed the preferred step therapy drugs. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Actemra. Our reviewer says that 
Actemra is not medically reasonable and necessary. The Plan requires a trial of Remicade, Inflectra, infliximab, 
or Simponi Aria before they will approve the requested drug. In this case, the patient has not tried and failed 
the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely 
be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the 
enrollee's condition does not meet step therapy criteria for Actemra. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Actemra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Actemra for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for an addition to lower extremity orthosis, high 
strength, lightweight material (L2755) and a partial foot, shoe insert with longitudinal arch, toe filler (L5000) 
provided on November 10, 2021. 
 
You asked the Plan to waive the coinsurance for an addition to lower extremity orthosis, high strength, 
lightweight material and a partial foot, shoe insert with longitudinal arch, toe filler. You say that there was no 
mention that this filler for your foot would not be covered. The Plan denied your request. The Plan says that 
you were charged the correct cost sharing amount. 
 
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 failed to return or respond to the request for the correct 2021 Evidence 
of Coverage (EOC). Therefore, we decided that the Plan has to waive the coinsurance for an addition to lower 
extremity orthosis, high strength, lightweight material (L2755) and a partial foot, shoe insert with longitudinal 
arch, toe filler (L5000) provided on November 10, 2021. 
  
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
November 7, 2021, to November 14, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that because you had the 
coronavirus (COVID-19), you were put in a private room. You also say that your insurance says it was charged 
too much for a private room, so you owe the rest. You also say that this is not fair that you are having to pay for 
something you have no control over. The Plan denied your request. The Plan says you were 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 $400 
copayment each day for days 1 to 4 for Medicare-covered hospital care.  
 You have been asked to pay a $400 copayment each day for 4 days of inpatient hospital services, which it a 
total of $1,600 ($400 x 4 = $1,600). Inpatient hospital services 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 inpatient hospital services provided from 
November 7, 2021, to November 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the enrollee exhausted her treatment options 
with the in-network provider and can no longer provide treatment. The Plan denied your request. The Plan says 
the provider is out-of-network. 
 
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 
the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a laboratory test (84153) provided on 
November 3, 2021. 
 
You asked the Plan to waive the copayment for the laboratory. You say that the services should be covered. 
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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $10 copayment for the laboratory test. Laboratory tests fall 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 a laboratory test (84153) provided on November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the orthotic fitting (physical therapy) on 
September 20, 2021, and the DME received on September 22, 2021. 
 
You asked the Plan to waive the cost sharing for the orthotic fitting and the durable medical equipment. You 
say that should have a physical therapy copay and not a DME copay. The Plan denied your request. The Plan 
says the cost sharing applied 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 $30 
copay for each Medicare-covered physical therapy visit and 20% coinsurance for covered DME items and 
related supplies.  
 
You have been asked to pay a total of $78.30 cost sharing for the physical therapy appointment and the DME 
item. $30 of this comes from the copay for physical therapy visit and $48.30 comes from coinsurance for the 
DME items ($241.50 x 20%). The orthotic fitting falls within the Outpatient rehabilitation services benefit 
category. The DME falls within the Durable medical equipment (DME) and related 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 cost sharing for the orthotic fitting (physical therapy) on 
September 20, 2021, and the DME received on September 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexlansopraz. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Dexlansopraz.  
 
Benefits for these services 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that your network urologist passed away. You say 
you were in an out-of-service area when you felt an acute pain resulting in a visit to an out-of-network 
provider. The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 
the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on November 4, 2021, and November 12, 2021 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered in full as they would cause a financial burden since you are on a fixed income. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for Ambulance services.  
 
 
  You have been asked to pay a $650 copayment for two ambulance transportation services ($325 x 2 = $640). 
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 ambulance transportation services provided on November 4, 
2021, and November 12, 2021