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

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from August 8, 2022, to August 30, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you were approved for additional 
days and still received a bill. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $188 
copayment per day for days 21-100 for skilled nursing facility (SNF) care.  
 
 
  The file shows that you were in the skilled nursing facility for 22 days from August 8, 2022, to August 30, 
2022. Therefore, you have been asked to pay a $188 copayment per day for days 21-22 for the SNF care. The 
total for the two days is $376. This item/service falls within the skilled nursing facility (SNF) 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 skilled nursing facility (SNF) care provided 
from August 8, 2022, to August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator 
provided on September 13, 2022. 
 
You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that this is too 
high of coinsurance to pay, and you cannot afford it. No one notified you that there was this cost associated 
with this item. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount for the equipment 
is $3080.95, of which 20% is $616.19 ($3080.95 x 20% = $616.19). 
 
You have been asked to pay a $616.19 coinsurance for an automatic external defibrillator. This item/service 
falls within the durable medical equipment (DME) 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 an automatic external defibrillator provided on 
September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says a prior authorization was not obtained prior to the services being 
rendered. 
 
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 September 20, 2022, by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on July 19, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 
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). Covered services 
include but are not limited to other outpatient diagnostic tests - Radiological diagnostic services, not including 
x-rays. The provider billed in the amount of $1,146 and the allowed amount is $108.99. This is less than the 
copayment amount. Therefore, results in the total cost sharing amount of $108.99. 
 
 
 You have been asked to pay a $108.99 copayment, which is less than the copayment for ultrasound. This 
item/service 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 on July 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the services requested can be provided safely in other settings, such as a long term 
care hospital, or skilled nursing facility. 
 
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 cannot tolerate or participate in intensive therapy. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on July 06, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that your provider ordered this, it should be covered. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for foot orthotics provided 
on July 06, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the OmniSeq Insight Solid tumor NGS panel (81455). 
 
You asked the Plan to pre-approve the laboratory services. You say that the test results will provide the treating 
physician with information on actionable markers of interest for the enrollee's specific cancer type and tumor 
profile as indicated by the National Comprehensive Cancer Network (NCCN) guidelines and Food and Drug 
Administration (FDA) label requirements. The Plan denied your request. The Plan says the request for 
OmniSeq Insight genetic testing panel is not approved and the enrollee does not meet Medicare criteria. The 
Plan states the records show the enrollee has recurrent lung cancer and this test was ordered for treatment 
guidance. 
 
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 laboratory services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found although testing may lead to suggestions for changes in treatment for this patient, the 
specific SNPs/components of the testing were not identified in the documentation as clinically relevant vs the 
entire panel. Also, the diagnosis is already clear and does not require additional confirmation which precludes 
this type of testing altogether based on the LCD. Therefore, this request for OmniSeq Insight Solid tumor NGS 
panel will be considered not medically necessary based on these requirements.  
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the OmniSeq Insight Solid tumor NGS panel (81455).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ophthalmology visit to be provided by the requested 
out-of-network provider 
 
You asked the Plan to pre-approve an Ophthalmology visit to be provided by the requested out-of-network 
provider. You say that you want to continue seeing this provider as this doctor knows your history and your 
mother goes to this provider. The Plan denied your request. The Plan says the member does not have benefits 
for elective 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 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 services. Therefore, we decided that the Plan does not have to pre-approve an 
Ophthalmology visit to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the astigmatism-correcting intraocular lens (A-C IOL) 
rendered on April 14, 2022. 
 
You asked the Plan to pay for these services. You say that you didn't want to wait until August of 2022 with the 
authorized provider. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the astigmatism-
correcting intraocular lens (A-C IOL) rendered on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says there is no referral or authorization on file for the services 
rendered. 
 
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 July 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on September 1, 
2022. 
 
You asked the Plan to waive the copayment for an injection. You say that this should be included in the regular 
office visit benefit. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment per visit for in-network outpatient surgery.  
 
You have been asked to pay $263.93 for an injection. This is less than the standard copayment amount. This 
item/service falls within the outpatient surgery 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 injection provided on September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says an authorization was not obtained prior to the services being provided. 
 
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 April 27, 2022, by an 
out-of-network (OON) provider.
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 needed to help you in your recovery. 
The Plan denied your request. The Plan says your needs can be met at an alternate 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 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 that the complexity of your nursing, medical and rehabilitation needs do not require 
an acute rehab 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, at an 
intensive rehabilitation therapy program. You can receive further services at 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix. 
 
You asked the Plan to pre-approve Vectibix. 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 Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Vectibix. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of stage metastatic rectal adenocarcinoma. The Food and Drug Administration has not stated that the 
requested drug regimen as prescribed is indicated for the enrollee's condition. The Medicare approved cancer 
drug compendia do not contain a supportive citation for the use of the requested drug regimen as prescribed in 
the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for 
review. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vectibix have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vectibix.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the copayment for inpatient hospital care provided from April 4, 2022, to 
April 11, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were admitted to the 
hospital and the staff still asked for the ER copayment. The Plan denied your request. The Plan says that this 
cost sharing was charged correctly. 
 
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 enrollees must pay a $0 copayment for inpatient hospital care.  
 
The Plan says you must pay a total of $100 for the inpatient care. Based on the Plan contract, however, you 
cannot be asked to pay more than a $0 copayment for the inpatient care. Therefore, we decided that the Plan 
has to waive the copayment for inpatient hospital care provided from April 4, 2022, to April 11, 2022.  
 
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 pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that a SNF admission is necessary. The Plan denied your 
request. The Plan says the enrollee does not have a decrease in function, and therefore, no skilled therapy is 
needed. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require skilled nursing and/or skilled therapy services on a daily 
basis. The enrollee is medically stable and can receive further rehabilitation services at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on May 26, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you believe this should be covered 
as a PCP visit. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for services obtained from a specialist. 
 
You have been asked to pay a $35 copayment for the office visit. This item/service falls within the services 
obtained from a specialist benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office 
visit provided on May 26, 2022.