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

We decided that the Plan does not have to waive the cost share for non-covered ambulance mileage provided 
on August 9, 2020. 
 
You asked the Plan to waive the cost share for non-covered ambulance mileage. You say that you do not agree 
with the extra charges The Plan denied your request. The Plan says you requested to go to a specific facility 
considered to be further away from the closest hospital to you. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you requested to go to specific hospital, which caused the extra mileage. Due to 
this reason the provider has billed a charge for extra mileage for the transport totaling $414.90. This is 
considered as non-covered by Medicare guidelines and is not a covered benefit. 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 cost share for non-covered ambulance mileage provided on August 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the psychotherapy services. The Plan denied your request. The Plan says 
you must receive care from in-network providers with the exception of emergency or urgent care, dialysis 
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, 
which requires prior authorization from the plan.  
 
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 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 
psychotherapy services to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for medical office visits (99213, 99214, 99406) 
on January 8, January 14, and February 27, 2020. 
 
You asked the Plan to waive the deductible for medical office visits. You say that these services should be 
covered as you are not well off financially. The Plan denied your request. The Plan says the correct cost-
sharing was applied. 
 
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 for Medicare-covered primary care physician or 
physician specialist services.  
 
The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner 
services, including doctors office visits" benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible for Medicare-covered primary care physician or 
physician specialist services. This cost sharing is a contractual obligation that had not been met at the time 
medical office visits were received on January 8, 2020 to February 27, 2020. Therefore, we decided that the 
Plan does not have to waive the deductible for medical office visits (99213, 99214, 99406) on January 8, 
January 14, and February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from July 15, 2020, through 
August 19, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.  
 
The Plan must follow Medicare rules. Medicare rules say that that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider at issue is a Mental Health 
Counselor. Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from 
July 15, 2020, through August 19, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia (J0897). You say that you want to continue treatment with this drug. 
The Plan denied your request. The Plan says that there is not enough information to determine medical 
necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Prolia (J0897). Our reviewer says that 
the drug is medically reasonable and necessary. Our physician reviewer found medical records have been 
submitted which confirm the diagnosis of osteoporosis, progression of osteoporosis while being treated with 
Actonel, and improvement in bone mineral density with Prolia which was started in October 2012.  Based on 
the documentation provided, ongoing treatment with Prolia is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia (J0897) have been met. Therefore, we decided that the Plan has to pre-
approve Prolia.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from January 1, 2020, through 
January 6, 2020. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says services provided 
by non-participating providers are not covered unless pre-authorized by the Plan. 
 
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 did not pre-approve the 
SNF services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for SNF services provided from January 1, 2020, through January 6, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued stay at an inpatient psychiatric hospital 
after November 18, 2020. 
 
You asked the Plan to pre-approve the continued stay at an inpatient psychiatric hospital. You say that 
continued inpatient psychiatric care is medically necessary. The Plan denied your request. The Plan says the 
clinical information did not support this continued level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 the continued stay at an inpatient 
psychiatric hospital. Our reviewer says that the continued stay at an inpatient psychiatric hospital is not 
medically necessary. Our physician reviewer found based upon review of the records provided it was not 
expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not 
showing any danger to self or others, no auditory or visual hallucinations and no abnormal behaviors. This 
patient was compliant with treatment. It did not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question 
as he did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. This patient does 
not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of 
 
 
November 19, 2020, forward and could have been treated in a lesser restrictive setting as he was not showing 
any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any behaviors being 
cooperative and compliant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continued stay at an inpatient psychiatric hospital have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the continued stay at an inpatient psychiatric 
hospital after November 18, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the capsule endoscopy you had on June 8, 
2020. 
 
You asked the Plan to waive the coinsurance for the capsule endoscopy. You say that because this test was 
unsuccessful, you should not have to pay cost sharing. The Plan denied your request. The Plan says you were 
charged this coinsurance 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.  
 
You have been asked to pay 20% coinsurance for the capsule endoscopy. The capsule endoscopy falls within 
the outpatient diagnostic tests benefit category. This cost sharing applies regardless of the success of the test. 
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 capsule endoscopy you had on June 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on February 10, 2020. 
 
You asked the Plan to waive the copayment for an X-ray. You say that you should only owe a $5 copayment 
because the X-ray was done at the doctor's office. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 X-rays provided at a primary care providers office, specialists office or at a freestanding facility 
and a $100 copayment for X-rays provided in an outpatient hospital facility.  
 
The record shows that you received an X-ray at an outpatient hospital facility on February 10, 2020. Therefore, 
you are responsible to pay the $100 copayment.  
 
You have been asked to pay a $100 copayment for an X-ray. An X-ray 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 copayment 
for an X-ray provided on February 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from May 21, 2020, 
to May 22, 2020. 
 
You asked the Plan to pay for the inpatient services. You say that the enrollee was admitted for persistent 
generalized weakness. The Plan denied your request. The Plan says the services could have been provided by a 
participating provider. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient services. Our physician 
reviewer found that the enrollee presented to the emergency room for the evaluation of weakness and chills. He 
was admitted to telemetry and evaluated by neurology. He underwent a swallowing evaluation and was 
evaluated by physical therapy. The enrollee was hemodynamically and neurologically stable, and appropriate 
for ambulance transport with monitoring to a Plan facility for continued inpatient level of care services. The 
treating physician did not document that the enrollee was not stable for transfer on any dates of service. 
Therefore, the post-stabilization services were not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient hospital services provided from May 21, 2020, to May 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the member does not have complex medical or intensive rehabilitation needs requiring supervision by a rehabilitation physician and an intensive and coordinated interdisciplinary team in a resource intensive inpatient hospital environment.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a lower GI bleed. The enrollee's medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 13, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on August 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forambulance services provided on April 13, 2020.You asked the Plan to waive the copayment forambulance services. You say that you did not know that the provider was out-of-network and would not have agreed to the services had you known.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 $350 copayment for ambulance services. You have been asked to pay the allowed amount of $321.60, which is less than the $350 copayment for ambulance services. Ambulance services fall within the ambulance 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 forambulance services provided on April 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the claim should be paid. The 
Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare when the 
record does not reflect a covered condition. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace provided to the enrollee on June 23, 2020. 
 
You asked the Plan to pay for the back brace. You say that the patient has had lower back pain for 2 years. The 
Plan denied your request. The Plan says that a review of the member?s claim history did not support the 
medical records provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the back brace provided to the 
enrollee on June 23, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a sleep study provided on July 8, 2020. 
 
You asked the Plan to waive the coinsurance for a sleep study. You say that the device did not work and you 
disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and 
you are being charged the correct amount. 
 
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 a sleep study. 
 
You received a sleep study on July 8, 2020. The total allowed amount is $325 and 20% of that is $65.   
 
You have been asked to pay the total coinsurance amount of $65 for a sleep study. A sleep study 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 coinsurance for a sleep study provided on July 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepalonosetron (J2469).You asked the Plan to pre-approvepalonosetron. You say that this is needed to prevent nausea and vomiting induced by the enrollee's treatment.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 palonosetron. Our reviewer says that the requested palonosetron is notmedically reasonable and necessary in this case. Our physician reviewer found palonosetronis FDA approved for the prevention of acute and delayed nausea and vomiting associated with initial and repeat courses in adults treated with moderately emetogenic cancer chemotherapy and theprevention of acute nausea and vomiting associated with initial and repeat courses in adults treated with highly emetogenic cancer chemotherapy. This patient is receiving low emetogenic chemotherapy.We looked at this physician'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of palonosetron have not been met.Therefore, we decided that the Plan does not have to pre-approvepalonosetron (J2469).