Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the chemotherapy services. We decided that the Plan 
does not have to waive the deductible for the chemotherapy services and pay for the self-administered drugs. 
 
You asked the Plan to waive the cost sharing and pay for these services. You say that the enrollee has not been 
charged before. The Plan says that the claim was processed correctly. 
 
We decided that the Plan has to waive the copayment for the chemotherapy services.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan says that enrollees must pay a 
4% coinsurance for each in-network outpatient hospital visit for chemotherapy services.  
 
Review of the file shows that the enrollee received chemotherapy at an in-network outpatient hospital on June 
16, 2021. The Plan charged a $25 copayment for these services; however, the Plan contract clearly states that 
there is a 4% coinsurance for each in-network outpatient hospital visit for chemotherapy services. The Plan 
applied the incorrect cost sharing for these services, Therefore, we decided that the Plan has to waive the 
copayment for the chemotherapy services rendered on June 16, 2021.  
 
We also decided that the Plan does not have to waive the deductible for the chemotherapy services and 
pay for the self-administered drugs. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 combined yearly deductible for your covered medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the in-network outpatient 
hospital visit for chemotherapy services benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $500 combined yearly deductible which applies to these services. This 
cost sharing is a contractual obligation that had not been met at the time these services were received on June 
16, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the chemotherapy 
services and pay for the self-administered drugs rendered on June 16, 2021.  
 
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 pay for the self-administered drugs 
rendered on June 16, 2021. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a positron emission tomography (PET) 
scan (78815) provided on January 6, 2022. 
 
You asked the Plan to waive the copayment for the PET scan. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on 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 $250 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 You have been asked to pay a $250 copayment for a PET scan. PET scans fall 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 a positron emission tomography (PET) scan (78815) provided on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory services provided on March 23, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Laboratory services. 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 Laboratory services provided on March 23, 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 left heart catheterization (93458) with inpatient hospital 
stay. 
 
You asked the Plan to pre-approve left heart catheterization. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure and 
associated inpatient hospital stay are not medically necessary. 
 
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 left heart catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is the medical appropriateness and necessity for performance of cardiac 
catheterization. A stress test was negative for ischemia, while an echocardiogram showed normal ventricular 
function. The medical records provided do not support the rationale for this invasive imaging study. Guidelines 
do not support a need for cardiac catheterization in this setting.  
 As a result, at this time cardiac catheterization would not be considered medically appropriate and necessary in 
this patients clinical management. The associated inpatient medical services are subsequently not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization (93458) with inpatient hospital stay.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
October 12, 2021, to October 28, 2021. 
 
You asked the Plan to pay for SNF services. You say that you billed according to what was approved, which 
was 17 days. The Plan denied your request. The Plan says you billed with an incorrect number of units on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for inpatient hospital and skilled nursing facility 
services, the number of days of care charged is always in units of full days.  However, the day of discharge, 
death, or a day on which a patient begins a leave of absence is not counted as a day unless discharge or death 
occurs on the date of admission.  In this case, the patient was admitted on October 12, 2021, and discharged 17 
days later of October 28, 2021.  In accordance with Medicare rules, the day of discharge is not counted as a day 
of coverage for SNF care.  You billed for 17 days of SNF care even though under Medicare rules, only 16 days 
are coverable.  This is true regardless of what was authorized. Please note that the Plan has advised that you 
may submit a corrected claim showing the actual number of billable days.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for 
skilled nursing facility (SNF) services provided from October 12, 2021, to October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for medical eye exam provided on March 14, 
2022. 
 
You asked the Plan to waive the copayment for medical eye exam. You say that this was a routine eye exam so 
you should not be charged. The Plan denied your request. The Plan says the copayment applied 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 a $45 
copayment for Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $45 copayment for medical eye exam. Medical eye exams fall within the Vision 
care benefit category. The records show a medical eye exam was performed. 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 medical eye exam provided on March 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of physical therapy services. 
 
You asked the Plan to pre-approve a continuation of physical therapy services. You say that additional physical 
therapy is appropriate to increase the enrollee's strength, range of motion, and to decrease pain. You say that a 
prior home exercise program has been ineffective for the enrollee. The Plan denied your request. The Plan says 
the enrollee does not meet the medical necessity criteria for the requested continuation of physical therapy 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 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 a continuation of physical therapy 
services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy 
generally is not accepted as specific and effective therapy for the enrollees condition beyond what was 
approved by the health plan. The enrollee has had prior therapy and the documentation does not reveal that the 
enrollee requires the unique skills of a professional therapist to safely and effectively provide treatment, that 
the services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
the enrollee's current condition or to prevent or slow further deterioration. The enrollee can transition to a home 
exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continuation of physical therapy services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuation of physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit provided on 
December 2, 2021. 
 
You asked the Plan to waive the deductible for a specialist office visit. You say that you do not understand why 
this claim was not covered since you were referred by your primary care physician. 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. Your 
contract with the Plan says that there is $500 deductible which applies to a specialist office visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. The item or service you asked 
the Plan to waive the deductible for falls within the Physician/Practitioner Services, Including Doctors Office 
Visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
$500 deductible which applies to a specialist office visit. This cost sharing is a contractual obligation that had 
not been met at the time a specialist office visit was received on December 2, 2021. Therefore, we decided that 
the Plan does not have to waive the deductible for a specialist office visit provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 31, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you are requesting 
reconsideration for the copayment specialist service. 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 $43 
copayment for services received from all in-network specialists. Covered services include consultation, 
diagnosis, and treatment by a specialist. 
 You have been asked to pay a $43 copayment for a specialist visit. The specialist visit falls within the 
Physician/Practitioner services, including doctor's office visits 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 a specialist visit provided on January 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta for the enrollee. 
 
You asked the Plan to pre-approve Neulasta. You say that the enrollee needs Neulasta for diagnosis of febrile 
neutropenia prophylaxis for standard of care for chemotherapy. The Plan denied your request. The Plan says 
that there is no indication that patient tried the preferred alternatives or has any adverse effects. 
 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 Neulasta. Our reviewer says that 
Neulasta is not medically reasonable and necessary for the enrollee. The enrollee has not tried Zarxio, 
Ziextenzo, Fulphila, Nyvepria or Udenyca. The Plan's required drugs would not likely be less effective and/or 
likely have adverse effects for the enrollee. They are likely to be as effective for the prevention of neutropenic 
fever. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for 
Neulasta. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient admission provided from January 1, 2022, to January 19, 
2022. 
 
You asked the Plan to pay for the inpatient admission. You say that you strongly believe that this acute 
inpatient admission was appropriate resulting in the patient's favorable outcome after inpatient treatment. The 
Plan denied your request. The Plan says that the enrollee was not covered under the medical plan during these 
dates of service. 
 
The Plan must follow Medicare rules. Medicare rules say that if coverage under a Medicare Advantage (MA) 
plan begins while the beneficiary is an inpatient in a hospital facility, payment for inpatient services until the 
date of the beneficiary's discharge is made by the previous MA organization, or Original Medicare, as 
appropriate. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient admission have been met. Therefore, we decided that the Plan has to pay for the 
inpatient admission provided from January 1, 2022, to January 19, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the surgery procedure provided on July 8, 
2021. 
 
You asked the Plan to waive the copayment for the surgery procedure. You say that you would like the 
copayment waived for the date of service and this procedure was a required. The Plan denied your request. The 
Plan says the proper 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 $295 
copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital 
facility.  
 
  You have been asked to pay a $295 copayment for the surgery procedure. The surgery procedure 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 the surgery procedure provided 
on July 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from February 23, 2021, to July 13, 2021. 
 
You asked the Plan to waive the copayments for the PT services. You say that you were not informed of any 
copayments at the times of the visits. 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 a $40 
copayment for each physical therapy visit.  
 
The file shows you had a total of 40 PT visits from February 23, 2021, to July 13, 2021. Therefore, you have 
been asked to pay a $40 copayment for 39 of the visits, and $39.34 for one visit. The total for all services is $1,599.34. The PT services fall within the Outpatient Rehabilitation 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 copayments for physical therapy (PT) services provided from February 23, 2021, to 
July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implantable infusion pump refill kit rendered on 
November 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of P are 
bundled/excluded codes. 
 
We looked at the file and Medicare rules. Billed procedure code A4220 has a status indicator of P and has no 
separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the implantable 
infusion pump refill kit rendered on November 23, 2021.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The 
Plan says that the enrollee could receive care in another setting. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a femur fracture after a fall. The enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation 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.