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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found continued care in the short-term acute care hospital is appropriate until the enrollee is 
stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation 
facility or a skilled nursing facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee's condition will not require a 25-day length of stay 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that the enrollee was admitted to the acute care hospital with abdominal pain related to small 
bowel obstruction related to recurrent bladder cancer. His hospital course was complicated by acute respiratory 
failure, sepsis, and encephalopathy. He appears to be more stable and improving and should only require short-
term additional acute care services that can be completed at the current facility. There are no services at the 
LTACH that he requires that are not already available and covered at the current facility. Transfer to LTACH is 
not medically necessary at this time as it would not be clinically advantageous. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is the most appropriate discharge 
option based on the enrollee's clinical status The Plan denied your request. The Plan says the enrollee's needs 
are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that the enrollee was admitted to the acute care hospital with osteomyelitis of vertebra and 
sacral pressure ulcer.  She appears to be stable and improving and should only require short-term additional 
acute care services that can be completed at the current facility. There are no services at the LTACH that the 
patient required that are not already available and covered at the current facility. Transfer to LTACH is not 
medically necessary at this time as it would not be clinically advantageous. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services provided on July 22, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
received are neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 office visit services provided on July 22, 2021, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81001, 87086) rendered by the out-
of-network (OON) provider on February 23, 2022. 
 
You asked the Plan to pay 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 services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided 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 laboratory services (81001, 87086) rendered by the out-of-network (OON) 
provider on February 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on May 
19, 2021. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that your PCP called the 
ambulance, and you were admitted the same day. The Plan denied your request. The Plan says coinsurance 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 $440 
copayment for each Medicare-covered one-way trip by ground ambulance.  
 
  You have been asked to pay $440 copayment for ambulance transportation. Ambulance transportation falls 
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 for 
ambulance transportation provided on May 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on January 
12, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you should not have to pay 
because it was not an emergency. You say you were told there would not be a charge. The Plan denied your 
request. The Plan says you have been charged the correct copayment 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 $250 
copayment per one-way trip depending upon the plan in which you are enrolled.  
 
You have been asked to pay $183.89 which is less than the standard $250 copayment. Ambulance transport 
falls 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 for 
ambulance transport provided on January 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on February 
24, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you asked at your pre-
registration appointment if your insurance would pay for all of the procedure. You feel that you should not owe 
the copayment. The Plan denied your request. The Plan says you have been charged the correct copayment 
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 $325 
copayment for surgical service at an in-network outpatient hospital facility.  
 
 
 
 
 You have been asked to pay a $325 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery provided 
on February 24, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on March 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) 
provider on September 16, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on  
September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on January 24, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that this test was a step in the process to 
see if you needed surgery, therefore you should not have to pay for the service. The Plan denied your request. 
The Plan says coinsurance 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 $185 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
  You have been asked to pay $152.26, which is less than the standard $185 copayment for an ultrasound. The 
ultrasound 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 ultrasound provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 12, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 an office visit provided on January 12, 2022 by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 
You asked the Plan to pre-approve the Synvisc. You say that Synvisc is medically necessary. The Plan denied 
your request. The Plan says a trial of Euflexxa, Durolane, Supartz-FX, or Gelsyn-3 is required before Synvisc 
can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Synvisc. Our reviewer says that 
Synvisc is not medically necessary. Our physician reviewer found the record shows no trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective. 
 
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 Synvisc have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Psychiatry provided from July 15, 2021 through October 14, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Psychiatry. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 Psychiatry provided from July 15, 2021 through 
October 14, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis treatment and cinacalcet (dialysis 
drug) provided from January 3, 2022, to February 28, 2022.  
 
You asked the Plan to waive the coinsurance for dialysis treatment and cinacalcet. You say that you are on a 
fixed income and cannot afford these payments. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 outpatient dialysis treatment. The Plan contract also says that enrollees must pay 20% coinsurance for Part B drugs. 
 
You have been asked to pay 20% coinsurance for each dialysis treatment from January 3, 2022, to February 28, 
2022. Dialysis treatment falls within the Services to Treat Kidney Disease benefit category. You have also been 
asked to pay 20% coinsurance for cinacalcet from January 3, 2022, to February 28, 2022. Cinacalcet falls 
within the Medicare Part B Prescription Drugs category benefit.  
 
Date of Service Code Allowed Amount 20% coinsurance 
January 3, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
January 5, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
January 7, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
January 10, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
January 12, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
January 14, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
January 18, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
January 21, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
January 24, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
January 26, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
January 28, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
January 31, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
    
Claim Total  $1,101.24 
   
February 2, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
February 4, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
February 7, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
February 9, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
February 11, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
February 16, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
February 18, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
February 21, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 February 23, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
February 25, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
February 28, 2022 90999 $449.87 $89.97 
 J0604 $9.00 $1.80 
Claim Total   $1009.47 
Total   $2110.71 
 
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 dialysis treatment and cinacalcet (dialysis drug) provided 
from January 3, 2022, to February 28, 2022.