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

 
We decided that the Plan does not have to pay for home infusion therapy services provided on January 29, 
2023, to February 02, 2023. 
 
You asked the Plan to pay for home infusion therapy services. You say that this is supported in the records. 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 home infusion therapy 
services provided on January 29, 2023, to February 02, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network procedure provided on April 
26, 2023. 
 
You asked the Plan to waive the copayment for an in-network procedure. You say that they were supposed to 
take the tube out of your neck, but it wasnt ready yet. The surgeon put a solution in the area instead. this was 
not a surgery. 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 $290 
copayment for Medicare-covered outpatient hospital facility visit. 
 
You have been asked to pay a $290 copayment for an in-network procedure. This item/service falls within the 
Medicare-covered outpatient hospital facility 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 in-network procedure provided on April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthotic shoe fitting and the shoe inserts to be 
provided by an OON provider.  
 
You asked the Plan to pre-approve an orthotic shoe fitting and the shoe inserts. You say that you are requesting 
reconsideration of the denied items. The Plan denied your request. The Plan says the items were not approved. 
 
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 orthotic shoe fitting and the shoe inserts to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care to be rendered by you, an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve continued chiropractic care. You say that the enrollee is a long-time patient, 
and you are requesting coverage because you are currently OON, but have started the process to become an in-
network provider. You also say that you are requesting authorization to see the patient in the meantime so they 
can use their benefits and not have to change caregivers for the short time frame of the credentialing process. 
The Plan denied your request. The Plan says services are not a covered benefit when services are available 
within the enrollee's plan. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 chiropractic care. Our 
reviewer says that this request for the enrollee to continue seeing you, an OON, provider is not medically 
reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has a history 
of lumbar subluxation. The Plan has indicated that in-network providers are available and capable of providing 
the care the enrollee needs. Our reviewer found that the record provided does not establish that the enrollee 
requires emergent or urgent care or that they are receiving active treatment such that transferring their care and 
medical management to another provider would be medically inappropriate and/or contraindicated at this time. 
The elements of the coverage criteria are not satisfied. Our physician reviewer also found that the requested 
service is not recommended. 
 
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 chiropractic care with you have not been met. Therefore, we decided 
that the Plan does not have to pre-approve chiropractic care to be rendered by you, an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia -first 15 minutes 
(D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), and therapeutic 
parenteral drugs, two or more administrations (D9612). 
 
You asked the Plan to pre-approve deep sedation/general anesthesia -first 15 minutes, deep sedation/general 
anesthesia - each subsequent 15-minute increment, and therapeutic parenteral drugs, two or more 
administrations. You say that the services are necessary. The Plan denied your request. The Plan says the 
requested services are not covered. 
 
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 pre-approve deep 
sedation/general anesthesia -first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-
minute increment (D9223), and therapeutic parenteral drugs, two or more administrations (D9612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 24, 2023. 
 
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 May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010). 
 
You asked the Plan to pre-approve the mastectomy sleeve. You say that this item is medically necessary. The 
Plan denied your request. The Plan says the requested item is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve (L8010) is denied as non-
covered since it does not meet the definition of a prosthesis. 
 
We looked at the file and Medicare rules. This item is non-covered. Based on this information, we decided that 
Medicare rules for coverage of the mastectomy sleeve have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a mastectomy sleeve (L8010).
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 the enrollee needs this care to improve their strength 
and endurance. The Plan denied your request. The Plan says the enrollee's condition does not meet the criteria 
for an IRF admission.  
 
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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure provided on 
April 17, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the pathology procedure. You say that this service was medically necessary. The 
Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the unlisted molecular pathology procedure provided on April 
17, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the radiation therapy provided on May 04, 
2023. 
 
You asked the Plan to waive the coinsurance for the radiation therapy. You say that you were unaware you had 
a coinsurance. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for the radiation therapy. 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. The total amount you owe is $44.86 ($224.28 
allowed amount x 20% = $44.86). Therefore, we decided that the Plan does not have to waive the coinsurance 
for the radiation therapy provided on May 04, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided from 
April 24, 2023, to April 30, 2023. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay. You say that you were supposed 
to only pay a $350 copayment for the surgery you had. You cannot afford this other cost. 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 $375 
copayment per day for days 1-5 for inpatient hospital services.  
 
You have been asked to pay a $1,875 copayment for an in-network inpatient stay. This item/service falls within 
the inpatient 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 an in-network inpatient stay provided from April 24, 2023, 
to April 30, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a PT evaluation and an OT evaluation 
provided on February 13, 2023. 
 
You asked the Plan to reduce the copayment for a PT evaluation and an OT evaluation. You say that you 
disagree with being charged two copayments for the same visit. 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 Medicare-covered occupational therapy, physical therapy, and speech language therapy visits.  
 
 You have been asked to pay a $70 copayment for a PT evaluation and an OT evaluation. This total includes a 
$35 copayment for the PT evaluation and a $35 copayment for the OT evaluation. This item/service falls within 
the outpatient rehabilitation 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 reduce the copayment for a 
PT evaluation and an OT evaluation provided on February 13, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on April 
19, 2023, and April 20, 2023. 
 
You asked the Plan to pay for the ED services. You say that you went to the nearest hospital and you were 
denied coverage. The Plan denied your request. The Plan says Medicare payment cannot be made to this type 
of provider. 
 The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on April 19, 
2023, and April 20, 2023.
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 services are medically necessary for the 
enrollee's complex medical care needs. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare's criteria for SNF 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 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 pre-approve surgical extraction of tooth #2 (D7210), deep 
sedation/general anesthesia first 15 minutes (D9222), deep sedation/general anesthesia  each subsequent 15-
minute increment (D9223), therapeutic parenteral drugs (D9612), and primary closure of sinus perforation 
(D7261). 
 
You asked the Plan to pre-approve surgical extraction of tooth #2, deep sedation/general anesthesia first 15 
minutes, deep sedation/general anesthesia  each subsequent 15-minute increment, therapeutic parenteral 
drugs, and primary closure of sinus perforation. You say that the services are necessary. The Plan denied your 
request. The Plan says the requested services are not covered. 
 
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 pre-approve 
surgical extraction of tooth #2 (D7210), deep sedation/general anesthesia first 15 minutes (D9222), deep 
sedation/general anesthesia  each subsequent 15-minute increment (D9223), therapeutic parenteral drugs 
(D9612), and primary closure of sinus perforation (D7261).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasound to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an ultrasound. You say that the enrollee has been referred to the provider for 
their expertise in pancreas disease. 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 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 ultrasound to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy procedure provided on May 
26, 2023. 
 
You asked the Plan to waive the copayment for the endoscopy procedure. You say that this service was 
medically necessary. 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 surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $250 copayment for the endoscopy procedure. This item/service falls within the 
outpatient surgery, including services provided at ambulatory surgical centers 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 endoscopy procedure provided on May 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mental health visit provided on May 16, 
2023. 
 
You asked the Plan to waive the copayment for a mental health visit. You say that you disagree 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 $20 
copayment for outpatient mental health care. 
 
You have been asked to pay a $20 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 May 16, 2023.