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. The Plan denied your request. The Plan says the enrollee does not 
require frequent rehab physician management, or an interdisciplinary approach to rehab care. 
 
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 physician reviewer found 
that the enrollee is at a minimal assist level for sitting up, moderate assist for standing, and minimal assist for 
lying down. He remains very weak with poor tolerance. The enrollee does not require the intensity of services 
provided at an IRF. Specifically, he is not shown to be able to perform fifteen hours per week of rehabilitative 
services with regular physician evaluation. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing applied to outpatient surgery services 
provided on January 3, January 10, and February 7, 2020. 
 
You asked the Plan to waive the cost-sharing applied to the outpatient surgery services. You say that you live 
on social security and work only 22 hours per week. You say that you only bring home $150 a week. You say 
that the cost-sharing amounts you are being expected to pay are a hardship. The Plan denied your request. The 
Plan says the cost-sharing was appropriately applied to the services provided. 
 
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% 
coinsurance for services provided in the outpatient department of a hospital.  
 
The records show that the amount allowed to be billed for the outpatient surgery services provided on January 
3, 2020 was $1,977.99. You have been asked to pay a 20% coinsurance for these outpatient surgery services, 
which totaled $395.60. The records show that the amount allowed to be billed for the outpatient surgery 
services provided on January 10, 2020 was $1,840.35. You have been asked to pay a 20% coinsurance for these 
outpatient services, which totaled $368.07. The records show that the amount allowed to be billed for the 
outpatient surgery services provided on February 7, 2020 was $1,840.35. You have been asked to pay a 20% 
coinsurance for these outpatient services, which totaled $368.07.  
 
The outpatient surgery services fall within the services provided in the outpatient department of a hospital 
benefit category. This means that you have been asked to pay the correct amounts 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-sharing applied to outpatient surgery 
services provided on January 3, January 10, and February 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) and a 
a TENS unit (E0745) provided to the enrollee on April 10, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
 
 
 
 
 
 
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with 
suspension sleeve (L1851, L2397) and a a TENS unit (E0745) provided to the enrollee on April 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance service and ground mileage provided on December 21, 2019.You asked the Plan to pay forthe ambulance service and ground mileage. You say that the enrollee was not in hospice at the time of the service.ThePlan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on December 17, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe ambulance service and ground mileage provided on December 21, 2019.
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 you recommend the enrollee receive therapy services 
in an inpatient rehabilitation facility in order to increase strength and mobility, as well as in an effort to restore 
the enrollee to her prior level of functioning. The Plan denied your request. The Plan says the IRF services are 
not medically 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 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. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that 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 does document 
a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. Our physician reviewer also found that there is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TECENTRIQ. 
 
You asked the Plan to pre-approve TECENTRIQ. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug 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 TECENTRIQ. Our reviewer says that 
the documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee is noted to have soft tissue sarcoma. Sarcoma is not a MAI for the use of 
atezolizumab. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TECENTRIQ have not been met. Therefore, we decided that the Plan does not 
have to pre-approve TECENTRIQ.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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. 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 do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record does document a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, first intraoral 
periapical x-ray, additional intraoral periapical x-ray, and bitewings provided on June 3, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, intraoral periapical x-rays, and 
bitewings. You say that this provider had been in-network in the past. You also say that since you were last 
seen, their credentialing had lapsed, and the office did not inform you. The Plan denied your request. The Plan 
says these services were rendered by an OON provider. The Plan also says that there were no calls prior to the 
appointment looking for a provider, or verifying the treating provider's network status. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation, prophylaxis, first intraoral periapical x-ray, additional intraoral periapical x-ray, and bitewings 
provided on June 3, 2020 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveModafinil.You asked the Plan to pre-approvethe Modafinil. You say that you would like reconsideration because the member has been taking this medication for many years and has done well.The Plan denied your request. The Plan says this drug is not covered for the member's condition by the Plan or Medicare Part B.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-approveModafinil.Benefits for the Modafinilmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on March 16, 2020. 
 
You asked the Plan to pay for the outpatient 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 
services at issue. 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 outpatient services provided on March 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a 
participating provider on March 26, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you do not feel like 
you should have to pay for the outpatient hospital facility charges. The Plan denied your request. The Plan says 
the correct copayment has been applied. 
 
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/outpatient surgery of procedure.  
 
You have been asked to pay $110.73 which is less than your copayment amount of $250 for outpatient hospital 
services. Outpatient hospital services fall within the outpatient hospital services/outpatient surgery of procedure 
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 outpatient hospital services 
provided by a participating provider on March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on June 8, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that there should be a $0 copayment 
because an annual physical was provided. The Plan denied your request. The Plan says an office visit was 
provided in addition to the annual physical. 
 
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 primary care visit.  
 
You have been asked to pay a $20 copayment for an office visit. The office visit falls within the primary care 
visit benefit category. The record indicates that this service was provided in addition to the annual physical you 
received on June 8, 2020. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit on June 8, 
2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 27, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe non-emergent ambulance services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says there are providers in-network available to render this service.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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would requirethe Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on March 27, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home services (99336) provided on 
May 21, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that medically necessary services were rendered in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-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 has network providers 
available who can provide the items/services 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 these items/services. 
Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home services (99336) 
provided on May 21, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should 
be waived. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $300 
per day copayment for days 1-5 for Inpatient Care.  
 
You have been asked to pay a $300 per day copayment for5 days of inpatient hospital care ($1,500). 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 inpatient hospital care provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a knee orthosis (brace) provided on 
January 15, 2020. 
 
You asked the Plan to waive the coinsurance for knee orthosis. You say that you believe you have been double-
billed for this item. The Plan denied your request. The Plan says the coinsurance amount you are being charged 
is correct. 
 
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 in-network knee orthosis. The allowed amount of this claim is $455.61, resulting in a 
coinsurance obligation of $91.12. 
 
You have been asked to pay 20% coinsurance for knee orthosis. Knee orthosis falls within the Prosthetic 
Devices 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. Therefore, we decided that the Plan does not have to waive the coinsurance for a knee 
orthosis (brace) provided on January 15, 2020.  
 
If the in-network provider is billing you for any amounts beyond the applicable cost-sharing for this claim, 
please contact the Plan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
January 7, 2020, to January 8, 2020. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that you would like the Plan to pay this 
amount. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. 
 
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 $450 
copayment per day for days 1 to 4 and $0 copayment for days 5 to 90 for in-network inpatient stay. This 
inpatient stay lasted 1 day, resulting in a copayment obligation of $450. 
 
You have been asked to pay $450 copayment per day for days 1 to 4 and $0 copayment for days 5 to 90 for 
inpatient stay. Inpatient stay 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 an inpatient hospital stay provided from January 7, 2020, to January 8, 2020.