Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that the enrollee does not require daily skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee requires continued skilled therapy and nursing. The reviewer found that care team 
documents need for continued medical monitoring of wound and blood pressure. The reviewer found that the 
enrollee is currently requiring physical assistance with mobility and activities of daily living complicated by 
Parkinson's disease documented by evaluating therapists. As a practical matter, the enrollee meets criteria for 
continued stay for daily skilled nursing/therapy in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you want to continue seeing the same provider. 
The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services can be received in-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 
an office visit 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 eyeglasses (V2020, V2025, V2750, V2755, V2784, 
V2203) provided on January 4, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you are unhappy that the plan is denying payment 
for your services. The Plan denied your request. The Plan says your vision benefit covers a maximum of $150 
toward the cost of routine eyewear every calendar year. The total cost of the eyeglasses purchased on January 
4, 2022, was $618. The Plan applied your full allowance at the time of services, and you are responsible for the 
remaining $468. Only the amount in excess of your annual allowance is the amount that is denied in this case. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $150 per calendar year. 
 
We looked at the file and the Plan's rules. The record shows that the Plan has applied the full allowance amount 
to this claim, and only the amount that exceeded this allowance has been denied. Based on this information, we 
decided that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, 
we decided that the Plan does not have to pay for the eyeglasses (V2020, V2025, V2750, V2755, V2784, 
V2203) provided on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist office visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve specialist office visits. You say that the providers listed on the denial are 
diagnostic radiologists and that is not the same specialty or services your doctors provide. You also say that 
your physicians are specialized in vascular and interventional radiology. The Plan denied your request. The 
Plan says the requested provider is not in the member's health plan, and the member has a shoulder condition 
that is not an emergency. The Plan also says that there are orthopedists in the member's health plan that he can 
see to evaluate and make a diagnosis and treat his shoulder pain. 
 
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 visits 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 surgery procedure (41899) provided on August 17, 
2021. 
 
You asked the Plan to pay for the dental procedure. You say that this service was medically necessary and 
should be covered by Medicare and paid. The Plan denied your request. The Plan says Medicare generally does 
not cover dental services. The procedure in this case was an extraction of a tooth due to a cavity. This 
procedure was not medical in nature and also was not part of planned treatment for a medical condition which 
is listed as a covered indication under Medicare rules. The provider in this case is not part of the Plan's 
specified dental vendor network for supplemental services. 
 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. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services 
obtained from providers who do not participate in the Plans specified supplemental dental vendor network are 
not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental surgery 
procedure (41899) provided on August 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on December 
20, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that while visiting your sister you 
started to feel nauseous and per the facilities policy they called for an ambulance. You also say you were 
treated by the ambulance crew but insisted you were fine and refused to go to the hospital. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for ambulance services. The contract also says that the copayment applies for evaluation, treatment, 
and transportation to the hospital. According to the EOC, the copayment still applies even if you were not transported to the hospital. You have 
been asked to pay a $225 copayment for ambulance services. Ambulance services falls within the Ambulance 
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 copayment for ambulance services 
provided on December 20, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for a hospital observation stay provided from January 4, 
2022, to January 7, 2022. 
 
You asked the Plan to reduce the copayment for a hospital observation stay. You say that the copayment 
amount is very high. You also say that you were given incorrect information from the insurance sales 
representative. The Plan denied your request. The Plan says that you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $90 copayment for in-network hospital observation 
services.  
 
The Plan says you must pay a total of $750 for an inpatient hospital stay. Based on the Plan contract, however, 
you cannot be asked to pay more than a $90 copayment for a hospital observation stay. The medical records 
show you were admitted for observation. Therefore, we decided that the Plan has to reduce the copayment for a 
hospital observation stay provided from January 4, 2022, to January 7, 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: 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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. All medically necessary care is being provided in the current acute care facility. 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 health plan. The health plan has approved ongoing care in the current acute care facility. 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the physical therapy services. You say that you are requesting an 
authorization for physical therapy. The Plan denied your request. The Plan says in-network providers were 
contacted and are able to provide the requested service. 
 
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 
physical therapy services to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist hospital visit provided on 
January 4, 2022. 
 
You asked the Plan to waive the copayment for a specialist hospital visit. You say that you are being billed for 
a doctor that came into your room for a brief second after surgery. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for an in-network specialist visit, including outpatient clinic visits.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$40 copayment for a specialist hospital visit. A specialist hospital visit falls within the an 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 copayment for a specialist hospital visit 
provided on January 4, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zirabev. 
 
You asked the Plan to pre-approve Zirabev. You say that the drugs have proven efficacy and safety in the 
treatment of recurrent ovarian cancer. The Plan denied your request. The Plan says that the requested use is not 
supported for the enrollee's condition. 
 
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 Zirabev. Our physician reviewer found 
that the enrollee has refractory ovarian cancer. The requested use of Zirabev is not FDA-approved for the 
enrollee's diagnosis. However, it is approved by clinical research that appears in a CMS-approved medical 
journal, JAMA Oncology, 2021. The requested use is not listed as not indicated, not supported or not 
recommended in any of the compendia. The documentation does support that the requested drug is safe and 
effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zirabev have been met. Therefore, we decided that the Plan has to pre-approve 
Zirabev.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the arm sling provided on January 20, 
2022. 
 
You asked the Plan to waive the coinsurance for an arm sling. You say that you were never told you would 
have to pay coinsurance for the sling. The Plan denied your request. The Plan says the coinsurance was applied 
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 20% 
coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies for the arm sling. 
The allowed amount was $710.08, resulting in a coinsurance amount of $142.01. 
 
 
 
 You have been asked to pay a total of $142.01 for the arm sling. An arm sling 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 coinsurance 
for the arm sling provided on January 20, 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 you feel that this higher level of care is needed. The 
Plan denied your request. The Plan says you do not meet Medicare criteria for IRF care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted to an acute hospital on 5/10/22 and underwent lumbar 
spinal fusion on 5/10/22 and Posterior bilateral L3-4 hemilaminectomy and fusion with instrumentation on 5/12/22 (stage 2). She was fitted with a back brace and discharged to a nursing home. On 5/17/22, she was at 
contact guard assist level for transfers and ambulation of 100 feet with rolling walker and contact guard assist 
with unsteady gait. 
 
The enrollee is medically stable and has no medical complexity and does not need supervision of a 
rehabilitation physician three times per week for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. At the current functional status, the enrollee does not need 3 hours a day five 
days a week of IRF therapies with interdisciplinary management. While the enrollee may benefit from further 
therapies, her rehab needs can be addressed at a low intensity 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 waive the coinsurance for a knee orthosis provided on December 29, 
2021. 
 
You asked the Plan to waive the coinsurance for a knee orthosis. You say that you were told that you would not 
pay anything out of pocket and are now getting billed a coinsurance. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare-covered orthotics.  
 
You have been asked to pay $89.49, which is 20% coinsurance of the allowed amount for a knee orthosis. A 
knee orthosis falls within the Prosthetic devices 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 coinsurance for a knee orthosis provided on December 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay from March 30, 
2021 through April 29, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that the enrollee was admitted 
to the hospital due to quality-of-care at a previous facility. You say that the enrollee should not have to pay this 
bill. The Plan denied your request. The Plan says copayment 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $295 for days 1-7 per admission and $0 for days 8-90 per admission.  
 
  The enrollee has been asked to pay $2,065 for the inpatient hospital stay ($295/day x 7 days = $2,065). The 
inpatient hospital stay falls within the Inpatient hospital 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 inpatient hospital stay from March 30, 2021 through April 29, 2021.