Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the rehabilitation center is necessary for the enrollee 
regaining independence and mobility. The enrollee desires to participate with the therapy recommended in 
order to accomplish goals to return home and be independent of daily needs.  The Plan denied your request. 
The Plan says based on Medicare guidelines, the IRF services you are requesting do not meet the 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a hip fracture and was transferred to skilled nursing on June 2, 2023. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. 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 records support 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. There is not a reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the radiation therapy services provided on 
December 28, 2022. 
 You asked the Plan to waive the coinsurance for the radiation therapy services. You say that you had already 
met your out-of-pocket maximum for 2022. 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 10% 
coinsurance for in-network outpatient radiation therapy services.  
 
The records show your 2022 out-of-pocket maximum was processed correctly. You have been asked to pay 
$3.61, which is 10% coinsurance of the allowed amount for the radiation therapy services ($36.13 allowed 
amount x 10% coinsurance = $3.61). This item/service falls within the outpatient diagnostic tests and 
therapeutic 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 coinsurance for the radiation 
therapy services provided on December 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the submitted medical records support the need for 
admission. The Plan denied your request. The Plan says the medical records submitted do not establish that the 
IRF admission is reasonable and necessary. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
anemia and gastrointestinal hemorrhage. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, there is no documented need for intensive rehabilitation services.  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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
April 1, 2022, to April 9, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you had met you 
maximum out-of-pocket prior to this claim. 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 $200 
copayment per day, for days 1 to 8 and a $0 copayment per day, for additional Medicare-covered days.  
 
The record shows you had met your maximum out-of-pocket amount during this claim. You have been asked to 
pay a $160.63 copayment per day, for days 1 to 8, which is less than the standard copayment for the inpatient 
hospital stay. You have been asked to pay a total of $1,285 ($160.63 copayment x 8 days = $1,285). You have 
not been charged for any additional days. 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 copayment for the inpatient hospital stay provided from April 
1, 2022, to April 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair.  
 
You asked the Plan to pre-approve a bath/shower chair. You say that you have Rheumatoid arthritis with 
rheumatoid factor of multiple sites without organ or systems involvement. You also say that you have medical 
limitations and you cannot bend so it is hard to take a shower.  The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that you filed the claim with Original Medicare in 
March of 2022. You claim that you did not receive information about the Plan until March of 2023. The Plan 
denied your request. The Plan says you did not timely file your claim. The Plan follows Medicare rules. The 
rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar 
year after the date of service. The record shows that a claim for the lab services was not filed until March 29, 
2023. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for lab services provided on February 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services provided on 
November 21, 2022. 
 
You asked the Plan to waive the copayment for the specialist services. You say that you never met with this 
provider. 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 $45 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $45 copayment for the specialist services. This item/service falls within the in-
network specialist physician/practitioner 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. The record shows this claim was approved and you are 
responsible for the cost share amount. Therefore, we decided that the Plan does not have to waive the 
copayment for the specialist services provided on November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 26, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. 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 laboratory services 
provided on April 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on January 12, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. A valid Appointment of Representative form or a Business 
Agreement have not been received. Based on this information, we decided that there is insufficient information 
in the record to determine if Medicare rules for coverage of a home visit have been met. Therefore, we decided 
that the Plan does not have to pay for the home visit provided on January 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
January 06, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room services. This item/service falls within 
the emergency 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 the emergency room 
services provided on January 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the exercise classes (S9451) 
purchased on January 1, 2022. 
 
You asked the Plan to issue additional reimbursement 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 you have 
exhausted the allowable benefit for these services.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
  
 
 
The Plans rules for coverage of gym benefits have not been met because you have exhausted the allowable 
benefit for these services. Specifically, the plan reimburses you up to $250 per calendar year for covered 
instructional fitness classes. The Plan previously issued reimbursement to you on March 10, 2023 in the 
amount of $250 for the exercise classes provided. Therefore, you have exhausted the allowable benefit for 
these services. Therefore, we decided that the Plan does not have to issue additional reimbursement for the 
exercise classes (S9451) purchased on January 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services, and travel allowance provided on October 25, 
2022. 
 
You asked the Plan to pay for lab services, and travel allowance. 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 lab services, and travel 
allowance provided on October 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF stay from January 1, 2023, through 
January 9, 2023. 
 
You asked the Plan to waive the copayment for SNF stay. You say that you should not be responsible for any 
cost of your SNF stay. 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 in-
network days 1-20: $0 copayment per day and days 21-100: $188 copayment per day. Also, you have an in-
network maximum out-of-pocket of $1,250. 
  You have been asked to pay $1,175, which is less than the standard $1,504 ($188/visit x 8 = $1,504) for the 
SNF stay. You also met your 2023 out-of-pocket annual maximum of $1,250. The records show you were 
billed $1,175 for date of  service (DOS) January 1, 2023, $15 for DOS January 13, 2023, $15 for DOS January 
13, 2023, $15 for DOS January 19, 2023, $15 for DOS February 8, 2023, and $15 for DOS February 10, 2023 
($15/per visit x 5 = $75 + $1,175 = $1,250). The SNF stay falls within the skilled nursing facility (SNF) care 
benefit category. The benefit period started in 2022; therefore, the 2022 benefits apply. 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 SNF stay from January 1, 2023, through January 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Orthovisc. 
 
You asked the Plan to pre-approve the tier exception for Orthovisc. You say that you cannot afford the drug. 
The Plan denied your request. The Plan says tier exceptions are not available for Part B drugs. 
 
The Plan must follow Medicare rules. Medicare rules say that each Part D plan sponsor that provides 
prescription drug benefits for Part D drugs and manages this benefit through the use of a tiered formulary must 
establish and maintain reasonable and complete exceptions procedures subject to CMS approval for this type 
of coverage determination. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Orthovisc have not been met. Specifically, tier exceptions cannot be granted for Part B drugs. 
Therefore, we decided that the Plan does not have to pre-approve a tier exception for Orthovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital bed, semi-electric provided on December 29, 2022. 
 
You asked the Plan to pay for hospital bed, semi-electric. You say that the supplies 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 hospital bed, semi-
electric provided on December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the collagenase injection provided on 
October 24, 2022. 
 
You asked the Plan to waive the coinsurance for the collagenase injection. You say that you were given 
incorrect cost share information from the Plan. 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 Part B drugs. 
 
You have been asked to pay 20% coinsurance for the collagenase injection. This item/service falls within the 
Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the 
collagenase injection provided on October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator 
provided on December 21, 2022. 
 
You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that you were not 
given a choice about using this item, and you sent it back. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the automatic external defibrillator. This item/service falls 
within the durable medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The total you owe is $616.19 ($3,080.95 allowed 
amount  x 20% coinsurance = $616.19). Therefore, we decided that the Plan does not have to waive the 
coinsurance for the automatic external defibrillator provided on December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft at time of implant placement (D6104 x2), 
surgical placement of implant body (D6010 x2), abutment supported crown (D6058 x2), guided tissue 
regeneration (D4266 x4), biologic materials to aid in tissue regeneration (D4265 x2), sinus augmentation with 
bone or bone substitutes (D7951 x2) and an unspecified implant procedure (D6199 x2). 
 
You asked the Plan to pre-approve the dental services. You say that it is very difficult for you to eat, and you 
only have your front teeth to chew your food. You say you have choked on your food, and it scares you 
because you can't breathe. The Plan denied your request. The Plan says dental codes D4266, D4265, D7951 
and D6199 are non-covered codes. The Plan also says the plan limits have been met on dental codes D6104 x2, 
D6010 x2 and D6058 x2. 
 
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, dental codes D4266, D4265, D7951 
and D6199 are not among those covered under this benefit. The plan limits have been met for dental codes 
D6104, D6010 and D6058. Therefore, we decided that the Plan does not have to pre-approve a bone graft at 
time of implant placement (D6104 x2), surgical placement of implant body (D6010 x2), abutment supported 
crown (D6058 x2), guided tissue regeneration (D4266 x4), biologic materials to aid in tissue regeneration 
(D4265 x2), sinus augmentation with bone or bone substitutes (D7951 x2) and an unspecified implant 
procedure (D6199 x2).