Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Diazepam 5mg tablet. 
 
You asked the Plan to pre-approve the medication. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says your plan has Part A and Part B coverage, with no Part D 
drug coverage. The Plan states that Medicare says Part B programs can only provide limited benefits for 
prescription drugs. 
 
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. The request is for oral medication, 5mg tablets. Therefore, this would usually be self-
administered, and this would also not be provided directly by the physician. Therefore, we decided that the 
Plan does not have to pre-approve Diazepam 5mg tablet.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda and ALIMTA. 
 
You asked the Plan to pre-approve Keytruda and ALIMTA. You say that the medications 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 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 Keytruda and ALIMTA. Our reviewer 
says that the medications are not medically necessary. Our physician reviewer found ALIMTA and Keytruda 
are not compendia supported for mesothelioma. In addition both drugs have been previously failed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda and ALIMTA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Keytruda and ALIMTA.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MILD procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that the enrollee is an excellent candidate for this 
service. The Plan denied your request. The Plan says the requested surgery is under investigation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the procedure is experimental. More research is needed to show the safety and efficacy of the 
procedure. It is not the standard 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MILD procedure for the enrollee.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that ongoing skilled services can be provided at a lower level of 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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. You 
are generally medically stable after acute on chronic CHF with Debility with no evidence of complex medical 
issues that require monitoring by an inpatient physical medicine and rehab physician three times per week or 
need for acute rehab nursing care. Whiles you may benefit from continuing physical therapy (PT) and 
occupational therapy (OT), there is no evidence of need for an intensive therapy program at the current 
functional tolerance level with therapy 3 hours per day with frequent physician oversight and an 
interdisciplinary approach to rehabilitation care. Admission to IRF is not medically necessary based on lack of 
medical complexity and current functional endurance and status. Your rehab needs can be met at an alternate, 
low intensity level setting. Our physician reviewer found that your 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost-sharing for podiatry services. We decided that the Plan does not 
have to reduce the cost-sharing for podiatry services.  
 
You asked the Plan to reduce the cost-sharing for podiatry services. You say that you already paid the $35 
office visit copayment at the time of the visit, and this doctor was rude to you. The Plan says that the cost-
sharing amount you are being charged is correct.  
 
We decided that the Plan has to reduce the cost-sharing for a podiatry office visit provided on May 22, 
2020.  
 
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 podiatry office visits are excluded from the Plan deductible. The Plan contract 
says that enrollees must pay $35 copayment for each podiatry office visit. 
 
The Plan says you must pay $44.76 deductible for podiatry office visit. Based on the Plan contract, however, 
the Plan deductible does not apply to podiatry office visit. You can only be asked to pay $35 copayment for 
podiatry office visit, which you say that you already paid at the time of service. Therefore, we decided that the 
Plan has to reduce the cost-sharing for podiatry services from $44.76 deductible amount to $35 copayment.  
 
We also decided that the Plan does not have to reduce the cost-sharing for podiatry surgical service 
provided on May 22, 2020. 
 
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 $750 
deductible for podiatry surgical service, even if the service is performed during an office visit that is excluded 
from the deductible. At the time this claim was processed, $0 of the $750 deductible amount had been met. The 
allowed amount of the surgery service is $108.64, resulting in a deductible obligation of $108.64. 
 
Therefore, we decided that the Plan does not have to reduce the cost-sharing for podiatry surgical service. 
 
Therefore, we decided that the Plan must reduce your total cost-sharing responsibility for this claim from 
$153.40 to $143.64. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 17, 2020 by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says prior authorization was not obtained by the provider or facility. 
 
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 medical services provided on April 17, 2020 
by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0427) provided on March 20, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $125 
copayment per one-way trip for emergency and non-emergency ambulance services.  
 
You have been asked to pay a $125 copayment for the one-way ambulance trip provided. 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 ambulance transportation service (A0427) provided on March 20, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on January 27, 
2020. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. 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 
service at issue. We found no exception that would require the Plan to pay for these iservices. Therefore, we 
decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on January 27, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 13, 2018 to April 
14, 2018. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary 
and the Plan should pay this claim. The Plan denied your request. The Plan says that inpatient services were not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee clearly met admission criteria with bradycardia, transient ischemic attack, 
leukopenia and possible acute coronary syndrome. The enrollee was not stable to transfer to a lower 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from April 13, 2018 to April 14, 2018.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the observation services provided from 
April 19, 2019 through April 23, 2019 by an in-network provider. 
 
You asked the Plan to waive the copayment for the observation services. You say that you need this changed to 
inpatient due to insurance policies. The Plan denied your request. The Plan says the claim was processed 
accordingly with your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Medical records support that you were admitted to an outpatient extended recovery and an outpatient 
observation status on April 19, 2019 per the dictated statements supplied by rendering physician, which aligns 
with how the claim was billed. The records support you were discharged home from an outpatient status on 
April 23, 2019. There is no record of the facility submitting a request to the Plan requesting an inpatient 
hospital stay. You were not formally admitted to inpatient hospital but were admitted to an outpatient extended 
recovery and observation status from April 19, 2019 through April 23, 2019, where you were discharged home. 
Your EOC states you pay $175 for each Medicare-covered outpatient hospital facility visit and $40 per day, per 
provider, for Medicare-covered lab services. 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 
observation services provided from April 19, 2019 through April 23, 2019 by an in-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
approved in advance. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on June 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit provided 
to the enrollee on April 9, 2020. 
 
You asked the Plan to pay for these services. You say that this item was medically necessary. The Plan denied 
your request. The Plan says that there are no clinical notes from the member's primary health provider. 
 
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 the neuromuscular 
stimulator, electronic shock unit provided to the enrollee on April 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 22, 2020. 
 
You asked the Plan to pay for the services provided. You say that the tests were provided as they were ordered 
by the referring physician. The Plan denied your request. The Plan says the service is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the 
documentation in the beneficiary's medical documentation. 
 
We find that the testing is not supported in the medical records. In this case, there are insufficient medical 
records to show that the results of the respiratory pathogen panel will determine a specific treatment strategy or 
diagnosis. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on April 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the benign lesion excision (11402) and the 
repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (12031) provided on June 15, 2020. 
 
You asked the Plan to waive the deductible 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 the deductible 
has been applied correctly 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 $750 
deductible each year. Additionally, enrollees must pay a $125 copayment after the deductible is met for each 
outpatient surgery and or services at an ambulatory surgical center or outpatient hospital facility.  
 
You have been asked to pay $540.79, which has been applied to your yearly deductible for the outpatient 
surgery provided. At the time of service, you had not met your deductible. Until you have paid the deductible 
amount, you must pay the full cost of your covered services. This amount applied to the deductible is the Plan 
allowed amount for the services provided. 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 deductible for the benign 
lesion excision (11402) and the repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (12031) 
provided on June 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 28, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the attending doctor wanted 
tests to be done and you were transported to another hospital. The Plan denied your request. The Plan says the 
claim was processed accordingly with your 2020 EOC benefits. 
 
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 show that you received ambulance services provided on March 28, 2020. You are asked to 
pay a $250 copayment for ambulance services. Your EOC states that enrollees must pay a $250 copayment for 
each one-way Medicare-covered ground trip. 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 ambulance 
services provided on March 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on March 15, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
available in-network. 
 
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 services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on March 
15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical or manipulative therapy performed for maintenance 
rather than restoration  (CPT Code S8990) provided on April 6, 2020. 
 
You asked the Plan to pay for the service. You say that you are appealing for reconsideration of the denied 
charges. The Plan denied your request. The Plan says the services you received are not listed as covered under 
the chiropractic benefit in your EOC. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for physical or manipulative therapy performed for maintenance rather than 
restoration  (CPT Code S8990) provided on April 6, 2020.