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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee requires continued rehabilitation 
services to get back to their baseline and is unsafe to return home at this time. The Plan denied your request. 
The Plan says the records do not show that the enrollee requires daily skilled nursing or therapy needs that can 
only be provided in a SNF.  
 
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 or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that the in-network providers in your area are not 
accepting new patients. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the inpatient hospital care provided by an 
in-network provider from February 19, 2023, to February 23, 2023. 
 
You asked the Plan to waive the cost sharing for the inpatient hospital care. You say that you are in a financial 
hardship. 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 $400 deductible which applies to in and out-of-network inpatient 
hospital care, and that you must pay a 25% coinsurance per admission for each in-network Medicare-covered 
inpatient stay. 
 
 You have been asked to pay a 25% coinsurance for the inpatient hospital care. You have also been asked to pay 
a $202.53 deductible for the inpatient hospital care. The item or service you asked the Plan to waive the cost 
sharing for falls within the inpatient hospital care benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $400 deductible which applies to inpatient hospital care. This 
cost sharing is a contractual obligation that had not been met at the time the inpatient hospital care was received 
from February 19, 2023, to February 23, 2023. Therefore, we decided that the Plan does not have to waive the 
cost sharing for the inpatient hospital care provided by an in-network provider from February 19, 2023, to 
February 23, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
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 reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the case file does not contain 
documentation of trial and failure of Orthovisc or Supartz FX. Our reviewer also found that the documentation 
does not support that Orthovisc or Supartz FX would likely be less effective, and/or would likely have adverse 
effects for the enrollee in this case.  
 
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 (J7323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a vascular laboratory visit provided on 
June 05, 2023. 
 
You asked the Plan to reduce the copayment for a vascular laboratory visit. You say that these types of tests do 
not cost this much, this copay is an outrageous amount. 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 $195 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $195 copayment for a vascular laboratory visit. 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. However, since the allowed amount is less than the 
standard copayment, you only owe $115.35 Therefore, we decided that the Plan does not have to reduce the 
copayment for a vascular laboratory visit provided on June 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the neuropsychological testing provided on 
September 21, 2023. 
 
You asked the Plan to waive the copayment for the neuropsychological testing. You say that you do not believe 
the services and copayment was applied correctly for the services received. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient hospital services. 
 
You have been asked to pay a $250 copayment for the neuropsychological testing. This item/service falls 
within the 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 
the neuropsychological testing provided on September 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on August 20, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that the payment for this oxygen equipment 
should not be bundled. The Plan denied your request. The Plan says you billed an incorrect Place of Service 
code on the claim for this equipment. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that providers 
must bill the appropriate POS code for services.  POS code 21 indicates that the services were performed in an 
inpatient hospital setting. POS code 22 indicates that the services were performed in an outpatient hospital 
setting. 
 
In this case, you billed the claim for these services with POS code 12 (home). However, the documentation 
shows that the patient was in an inpatient hospital status on the date of service billed. As a result, POS code 21 
should have been used on the claim instead.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay 
for oxygen equipment provided on August 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 
You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says this medication is not 
approved for use in men and is being studied. 
 
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 Evenity. Our reviewer says that Evenity 
is not medically reasonable and necessary for the enrollee. Our physician reviewer found the review has 
determined that the requested use of Evenity (J3111) is not FDA-approved for the enrollee's diagnosis. Our 
reviewer also found that its use is not supported by one of the major drug compendia or by clinical research 
that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric admission provided on June 07, 
2023, to July 01, 2023. 
 
You asked the Plan to pay for the inpatient psychiatric admission. You say that the services should be covered 
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 psychiatric 
admission provided on June 07, 2023, to July 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit (90834) provided on September 1, 
2023 provided on September 01, 2023. 
 
You asked the Plan to pay for a psychotherapy visit (90834) provided on September 1, 2023. You say that you 
disagree with the denial and have submitted medical records for review. 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 psychotherapy visit 
(90834) provided on September 1, 2023 provided on September 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the x-rays and the office visit on October 
5, 2023. 
 
You asked the Plan to waive the copayments for the x-rays and the office visit. You say that you go to the 
provider for a yearly kidney check and that previously, you were told with other plans, you only had one copay. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for each x-ray service. You must pay a $30 copay per specialist in-person or telehealth visit. For 
both services it's $20 + $30 = $50. Therefore, results in the total cost sharing amount of $50. 
 
You have been asked to pay a $20 copayment for the x-rays and a $30 copayment for the office visit. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies and 
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 copayments for the x-rays and the office visit on October 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 24, 2023, by an out-of-
network (OON) provider.  
 You asked the Plan to pay for the office visit. You say that the medical records show medical necessity and ask 
that the Plan to reconsider payment. The Plan denied your request. The Plan says there was no authorization for 
the services. 
 
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. This service was not routine dental care. 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 the office 
visit provided on August 24, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ingrezza. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that self-administered 
drugs do not fall under Medicare Part b coverage. 
 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 Ingrezza.  
 
Benefits for the drug 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2.  
You asked the Plan to pre-approve a Freestyle Libre 2. The Plan denied your request. The Plan says the patient 
does not meet the criteria for coverage. 
 
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 indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
September 01, 2023. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not agree with 
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 $95 
copayment for each Medicare-covered emergency room visit. 
 
You have been asked to pay a $95 copayment for an emergency room visit. This item/service falls within the 
each Medicare-covered emergency room visit 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 September 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on April 18, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that this patient is in a facility, and you depend 
upon the facility staff for any verification or prior 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 nursing facility visit 
provided on April 18, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mental health visit provided on July 13, 
2023. 
 
You asked the Plan to waive the copayment for a mental health visit. You say that you did not authorize this 
provider to see the beneficiary. You feel this is a fraudulent charge. 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 $30 
copayment for outpatient mental health care. 
 
You have been asked to pay a $30 copayment for a mental health visit. This item/service falls within the 
outpatient mental health 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 mental 
health visit provided on July 13, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 You asked the Plan to pre-approve Aranesp. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Aranesp. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the lab services provided by an in-network 
provider on June 3, 2023. 
 
You asked the Plan to waive the deductible for the lab services. You say that you do not agree with the cost 
sharing. 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 $525 in-network deductible which applies to in-network lab services. 
 
You have been asked to pay a $86.78 deductible for the lab services. The items or services you asked the Plan 
to waive the deductible for fall within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $525 
in-network deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This 
cost sharing is a contractual obligation that had not been met at the time the lab services were received on June 
3, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the lab services provided 
by an in-network provider on June 3, 2023.