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

 
We decided that the Plan does not have to pay for principal care management services provided on March 17, 
2023. 
 
You asked the Plan to pay for principal care management services. You say that you have no prior knowledge 
of who you would be seeing. 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 principal care 
management services provided on March 17, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that the provider does not carry Orthovisc in this office. 
The Plan denied your request. The Plan says the enrollee has not tried one of the preferred products.  
 
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 Euflexxa. Our physician reviewer found 
that the enrollee has osteoarthritis of the left knee. The Plan requires a trial of Monovisc, Orthovisc, Synvisc, or 
Synvisc One before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the Plans required drugs would likely be 
less effective and/or likely have adverse effects for the 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of aorta, inferior vena cava, iliac vasculature, or 
bypass grafts; complete study rendered on January 30, 2023. 
 
You asked the Plan to pay for the scan. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare says screening services performed for a purpose other than treatment or 
diagnosis of a specific illness, symptoms, complaint, or injury are excluded from coverage. 
 
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 scan. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the rationale for the exam is unclear, as is how the enrollee's clinical management would change as a 
result of the test. As such, there is no evidence to suggest a need to perform a screening duplex ultrasound 
exam of the aorta. In summary, there is insufficient documentation to support the medical necessity for 
screening duplex ultrasound exam of abdominal aorta. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pay for duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study rendered 
on January 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on March 10, 2023. 
 
You asked the Plan to pay for inpatient hospital care. You say that you are appealing the claim payment denial. 
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 inpatient hospital care 
provided on March 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth service provided on February 28, 2023. 
 
You asked the Plan to pay for a telehealth service. You say that you were the only provider available at this 
time to speak to the patient, who was home bound with COVID. 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 telehealth service 
provided on February 28, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular monitoring services provided on October 16, 
2022. 
 
You asked the Plan to pay for cardiovascular monitoring services. You say that you doctor ordered this and it is 
a yearly test. It should be covered without issue. 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 cardiovascular 
monitoring services provided on October 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
August 23, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not think you 
should be responsible for this copayment. 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 $90 
copayment for emergency room visits in the United States. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
emergency room visits in the United States benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an emergency room visit provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on February 15, 2023, by an out-of-
network (OON) provider.  
 
 
 You asked the Plan to pay for home visit. You say that the member was in an assisted living facility, and this 
should be covered. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee 
receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home visit provided on February 15, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 12, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 an office visit provided 
on December 12, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 21, 2022,  
through October 26, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) on October 21, 2022 with mental status 
changes and decreased oral intake. She was evaluated and treated with intravenous fluids and insertion of a 
foley catheter and admitted. Discussion took place regarding potential percutaneous endoscopic gastrostomy 
(PEG) insertion but her family declined. The chest x-ray revealed bilateral pleural effusions and she was 
evaluated by Pulmonary. She was ultimately transitioned to comfort care and was discharged to a hospice 
facility on October 26, 2022. The review has determined that the record showed that at the time of the inpatient 
admission the admitting physician reasonably expected that the enrollees necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from October 21, 2022,  through 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator, and a portable 
oxygen concentrator provided on January 31, 2023, to February 28, 2023. 
 
You asked the Plan to waive the coinsurance for an oxygen concentrator, and a portable oxygen concentrator. 
You say that you do not think you should be responsible for the cost share. 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 20% 
coinsurance for Medicare oxygen equipment. 
 
You have been asked to pay 20% coinsurance for an oxygen concentrator, and a portable oxygen concentrator. 
This item/service falls within the Medicare oxygen equipment 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. The total you owe is $78.56 ($392.78 allowed 
amount x 20% = $78.56 rounded up). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an oxygen concentrator, and a portable oxygen concentrator provided on January 31, 2023, to 
February 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuplazid 
 
You asked the Plan to pre-approve Nuplazid. You say that the enrollee has been on this medication since 2020. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Nuplazid  Benefits for Nuplazid 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care provided on December 21, 
2022. 
 
You asked the Plan to pay for a subsequent nursing facility care. You say that it is the responsibility of the 
facility 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 subsequent nursing 
facility care provided on December 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit provided on December 22, 2022. 
 
You asked the Plan to pay for nursing facility visit. You say that you are appealing the claim payment denial. 
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 nursing facility visit 
provided on December 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
August 10, 2021, through September 29, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services at issue are not payable as the 
provider is not enrolled in the Medicare program.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the acute inpatient psychiatric hospital 
care provided from August 10, 2021, through September 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital stay provided on May 06, 2023, to May 
10, 2023. 
 
You asked the Plan to pay for the inpatient hospital stay. You say that the hospital is responsible to obtain prior 
authorization for all of their patients. 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 the inpatient hospital 
stay provided on May 06, 2023, to May 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 19, 2022, to 
August 16, 2022. 
 
You asked the Plan to pay for the home health services. 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 as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, revenue 
code 0023 was not submitted correctly per Medicare guidelines. Therefore, we decided that the Plan does not 
have to pay for the home health services provided from July 19, 2022, to August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a new patient office visit provided on 
March 22, 2023. 
 
You asked the Plan to waive the copayment for a new patient office visit. You say that you do not agree with 
paying the copayment. 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 $35 
copayment for in-network Medicare-covered visits with a specialist. 
 
You have been asked to pay a $35 copayment for a new patient office visit. This item/service falls within the 
in-network Medicare-covered visits with a specialist 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 new patient office visit provided on March 22, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that admission to a SNF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for SNF 
care. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.