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

 
We decided that the Plan does not have to pay for angioplasty provided on March 16, 2023. 
 
You asked the Plan to pay for angioplasty. You say that you are requesting the submitted documentation be 
reviewed. 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 angioplasty provided on 
March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on March 24, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that these supplies are a separately billable 
expense that do not require separate 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 the wound care supplies 
provided on March 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an in-network inpatient stay provided 
from January 10, 2023, to January 18, 2023. 
 
You asked the Plan to waive the copayments for an in-network inpatient stay. You say that you fell multiple 
times through you inpatient stay here and should not have to pay these copayments. 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 $150 
copayment per inpatient stay for inpatient hospital care.  
 
You had multiple stays, resulting in a $300 total copayment ($150 x 2 = $300). 
 You have been asked to pay a $300 total copayment for an in-network inpatient stay. This item/service 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 copayments for 
an in-network inpatient stay provided from January 10, 2023, to January 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for lab testing and electrocardiogram (ECG) 
on Mach 06, 2023. 
 
You asked the Plan to waive the copayments for lab testing and ECG. You say that you don't know why you 
are being charged the $5 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 $5 
copayment for $5 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per 
facility). You must pay a $20 copayment after the deductible is met for each basic imaging service (e.g., 
general x-rays or ultrasound). Covered services include but are not limited to laboratory tests and other 
outpatient diagnostic tests. There were two services done. The plan only assessed a $5 copayment for the ECG.  
2 x $5 = $10. Therefore, results in the total cost sharing amount of $10. 
 
You have been asked to pay a $5 copayment for lab testing and a $5 copayment for ECG. 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 copayments for lab testing and electrocardiogram (ECG) on Mach 06, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the intraocular lens procedure provided on 
January 19, 2023. 
 
You asked the Plan to waive the deductible for the lens procedure. You say that you don't understand why you 
are being charged. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to an intraocular lens procedure.  
 
You have been asked to pay $560.76 towards the deductible for the lens procedure. The item or service you 
asked the Plan to waive the deductible for falls within the outpatient surgery, including services provided at 
ambulatory surgical centers benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $750 deductible which applies to outpatient surgery, including services provided at 
ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time an 
intraocular lens procedure was received on January 19, 2023. Therefore, we decided that the Plan does not have 
to waive the deductible for the intraocular lens procedure provided on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on February 13, 
2023. 
 
You asked the Plan to waive the copayment for an office 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 $35 
copayment for in-network provider and professional services provided in a specialists office. 
 
You have been asked to pay a $35 copayment for an office visit. This item/service falls within the in-network provider and professional services provided in a specialists office 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 office visit provided on February 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on April 14, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for procedure code J3490 is included in the global surgery 
payment for procedure code 64493 provided on April 14, 2023. Separate payment cannot be made for 
procedure code J3490. Based on this information, we decided that Medicare rules for coverage of procedure 
code J3490 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
J3490 provided on April 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skyrizi. 
 
You asked the Plan to pre-approve Skyrizi. The Plan denied your request. The Plan says the drug is not covered 
for the enrollee's condition.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Skyrizi. Our physician reviewer found 
that the enrollee has ulcerative (chronic) rectosigmoiditis with rectal bleeding. The requested use of Skyrizi is 
not FDA approved for the enrollee's diagnosis. Skyrizi is FDA-approved for the treatment of moderately to 
severely active Crohn's disease in adults. There is insufficient support in the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal, for the use of Skyrizi in the treatment of 
ulcerative colitis. The documentation does not 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 Skyrizi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Skyrizi.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subcutaneous cardiac rhythm monitor system provided on 
December 29, 2022. 
 
You asked the Plan to pay for subcutaneous cardiac rhythm monitor system. You say that you are requesting a 
reconsideration of the denied charges. 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 subcutaneous cardiac 
rhythm monitor system provided on December 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from December 1, 
2022, to January 27, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were not aware of the cost share 
for days 21 to 80 and cannot afford to pay the copayments. 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 $0 
copayment for days 1 to 20 and a $188 copayment per day for days 21 to 80 for SNF care in 2022 and $0 
copayment for days 1 to 20 and a $196 copayment per day for days 21 to 80 for SNF care in 2023. 
  
You have been asked to pay a total copayment of $8,292 for a SNF stay. This total includes a $3,196 
copayment for a SNF stay provided from December 1, 2022, to December 31, 2022 ($188 per day x 17 days = 
$3,196) and a $5,096 copayment for a SNF stay provided from January 1, 2023, to January 27, 2023 ($196 per 
day x 26 days = $5,096). This item/service falls within the SNF 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 a SNF stay provided from December 1, 2022, to January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
March 31, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the exam was 
incomplete. 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 $25 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the specialist office visit provided on March 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hydrocortisone acetate (J3490). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee really needs the suppository to 
help with the healing of their hemorrhoids. 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 hydrocortisone acetate 
(J3490).  
 
Benefits for the medication 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued hospital care after July 19, 2023. 
 
You asked the Plan to pre-approve continued hospital care after July 19, 2023. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 pre-approve continued hospital care after July 19, 
2023. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided medical records indicate that you were 
clinically stable for discharge with no need for continued inpatient hospital care after July 19, 2023. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued hospital care after July 19, 2023, have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued hospital care after July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish and periodontal 
scaling and root planing (D4342, D1206) provided on January 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
topical application of fluoride varnish and periodontal scaling and root planing (D4342, D1206) provided on 
January 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin or 
has a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network gastroenterologist. 
 
You asked the Plan to pre-approve these services. You say that the requested provider is the only one within 
reasonable distance that is accepting new patients. The Plan denied your request. The Plan says the services are 
available from network 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. The file shows that the requested provider is 35.6 miles from your residence and that you are currently seeing a network provider that is located 17.5 
miles from your residence. 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 a referral to an out-of-network 
gastroenterologist.
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 cannot go home or to a nursing facility, as you 
still need therapy to regain maximum strength. The Plan denied your request. The Plan says that you do not 
meet requirements for approval. 
 
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 your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), 
prophylaxis (D1110), bitewing x-rays (D0272), periapical first x-ray (D0220) and periapical each additional x-
ray (D0230 x 3) provided on March 20, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were informed that your provider was 
in-network. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted and you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider.  
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, the record shows your benefit for periapical x-rays was exhausted on March 20, 2023. Therefore, 
we decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), 
prophylaxis (D1110), bitewing x-rays (D0272), periapical first x-ray (D0220) and periapical each additional x-
ray (D0230 x 3) provided on March 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drug, oxycodone-acetaminophen. 
 
You asked the Plan to pre-approve the medication. 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 the drug, oxycodone-
acetaminophen.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.