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

 
We decided that the Plan does not have to reduce the cost for the laparoscopy provided on January 13, 2022. 
 
You asked the Plan to reduce the cost for a laparoscopy. You say that you met your deductible. You say that 
you paid the copayment so you should owe nothing. The Plan denied your request. The Plan says the 
deductible is the amount you must pay for medical services before our plan begins to pay its share. 
 
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 $345 copayment, after your $1,000 plan deductible, for each 
Medicare-covered outpatient surgery at an outpatient hospital facility. 
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible 
which applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the 
time the laparoscopy was received on January 13, 2022. Therefore, $1,000 has been applied to meet your 
deductible.  Since your $1,000 deductible was met, you have also been asked to pay a $345 copayment for the laparoscopy. 
The total amount you owe is $1,345 ($1,000 deductible + $345 copayment = $1,345). 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 reduce the cost for the laparoscopy provided on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
February 3, 2022. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that the provider never told 
you it was a telephone evaluation. The Plan denied your request. The Plan says documentation confirmed a 
telehealth visit was done and they reprocessed the claim and applied the proper copayment. 
 
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 $30 
copayment for each telehealth specialist visit.  
 
  You have been asked to pay a $30 copayment for a specialist telehealth visit. The specialist telehealth 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 telehealth visit provided on February 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 23, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the doctor's office failed to send in a 
preauthorization form for approval. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 
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 February 23, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
February 2, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you went to be tested for pneumonia 
due to your COVID-19 diagnosis. 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 $75 
copayment for emergency room visits.  
 
You have been asked to pay a $75 copayment for the ER visit. Please note that cost share waivers only apply to 
COVID-19 testing and vaccines. The ER visit falls within the Emergency Care benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an emergency room (ER) visit provided on February 2, 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 you need IRF care to get stronger so you do not end 
up back in the hospital. The Plan denied your request. The Plan says based on Medicare guidelines, the 
requested IRF services do not meet the requirements for approval. 
 
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 enrollee is medically stable and does not need physical medicine and rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. You have no acute rehab nursing needs identified 
or documented. At your current level of function, you do not need intensive therapies consisting of at least 3 
hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. An IRF admission 
is not medically necessary based lack of medical complexity and acute rehabilitation nursing needs. While you 
may benefit from continued physical therapy and occupational therapy, your rehabilitation needs can be safely 
provided in a lower intensity and alternate setting. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) of the 
abdomen and pelvis (74176) provided on January 20, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you asked your primary care 
provider if there would be a copayment for this service, and you were told that the provider of the service 
would be able to tell you that information. The Plan denied your request. The Plan says this claim was 
processed correctly, and your copayment was assessed in accordance with your contract. 
 
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 $50 
copayment for a Medicare-Covered Diagnostic CAT scan at a freestanding provider.  
 
 
 
 You have been asked to pay a $50 copayment for the CT scan. A CT scan falls within the Medicare-covered 
diagnostic CAT scan benefit category, and in this case the CT scan was performed at a freestanding facility. 
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 computed tomography (CT) of the abdomen and pelvis 
(74176) provided on January 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care visits. 
 
You asked the Plan to pre-approve home health care. You say that the requested provider has been your home 
health provider of choice for 5 years. The Plan denied your request. The Plan says you were already approved 
for other visiting nursing services and it is unclear if this request duplicates what was already approved. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health care. Our reviewer says 
that you do not meet the Medicare criteria for the requested home health care. Our physician reviewer found 
you do not have documented skilled nursing needs and are not homebound. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health care visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that please provide 
out of network authorization. There is no other supplier in the geographical area that can provide the prescribed 
equipment. The Plan denied your request. The Plan says enrollees must receive their medical services from an 
in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before 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 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on January 11, 2022. 
 
You asked the Plan to pay for a nursing facility care visit. You say that the provider saw the enrollee in a 
hospital and should not be penalized for the failure of the hospital to obtain authorization. The Plan denied your 
request. The Plan says the out-of-network services were not authorized. 
 
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 a nursing facility care visit provided on January 
11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Carboplatin, and Pemetrexed. 
 
You asked the Plan to pre-approve Keytruda, Carboplatin, and Pemetrexed. You say that this drug regimen is 
medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have 
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 Keytruda, Carboplatin, and 
Pemetrexed. Our reviewer says that the requested drugs are not medically reasonable and necessary. Our 
physician reviewer found the enrollee is a 69-year-old male diagnosed with stage IIIB non-small cell lung 
cancer. In this case, the requested use of Keytruda, Carboplatin, and Pemetrexed is not FDA-approved for the 
enrollees diagnosis as the enrollee has progression of disease on immunotherapy. This drug regimen is not 
FDA-approved when there is progression of disease on immunotherapy. In addition, the use of these drugs is 
not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. The Medicare criteria for coverage of the requested drugs have not been met. 
 
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, Carboplatin, and Pemetrexed have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Keytruda, Carboplatin, and Pemetrexed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for magnetic resonance imaging (MRI) of the 
pelvis and a gadobutrol injection (A9585) provided on March 21, 2022. 
 
You asked the Plan to waive the cost-share for the MRI and drug injection. You say that you should not be 
responsible for this cost-share since this information was not listed on your member ID card. The Plan denied 
your request. The Plan says this claim was processed in accordance with your contract. 
 
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 $175 
copayment for diagnostic imaging services and 20% coinsurance for Medicare Part B prescription drugs.  
 
The purpose of a member ID card is to identify you as a member of the plan. One purpose of the Evidence of 
Coverage is to outline your benefits, including copayments, deductibles and coinsurance amounts for a wide 
array of covered services. You have been asked to pay a $175 copayment for the MRI and 20% coinsurance for the related drug injection. The MRI falls within the diagnostic imaging services benefit category. A drug 
injection falls within the Medicare Part B prescription drugs benefit category. The provider billed $525 for the 
injection, but the Plans allowed cost for this service is $36.75. That means that this is the amount that is treated 
as full payment for this service. You are responsible for 20% coinsurance on the Plans allowed cost, and are 
being asked to pay $7.35 for the injection. ($36.75 x 20% = $7.35). 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 
cost-share for magnetic resonance imaging (MRI) of the pelvis and a gadobutrol injection (A9585) provided on 
March 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan provided on January 14, 
2022. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that you already paid the $35 when you 
were at the doctor's office. 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 $150 
copayment for Medicare-covered radiological diagnostic services, not including x-rays performed in a 
physician's office or at a free-standing facility (such as radiology center or medical clinic).  
 
 
 You have been asked to pay a $150 copayment for a duplex scan. The duplex scan 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 a duplex scan provided on January 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on May 15, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says the 
Plan did not receive the primary carrier's Explanation of Benefit. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
the Explanation of Benefit from the primary carrier. As the secondary insurer, the Plan cannot be held 
responsible for the emergency department visit until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
May 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a room humidifier. 
 
You asked the Plan to pre-approve a room humidifier. You say that you wake up every morning so dry and 
almost choking. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve a room humidifier.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services provided on 
January 14, 2022. 
 
You asked the Plan to waive the copayment for the outpatient hospital services. You say that you went to see 
your physician and had an exam in his office. The Plan denied your request. The Plan says the proper 
copayment was applied for the service that was billed. Also, they confirmed the provider billed there location 
properly. 
 
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 Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. The total amount allowed 
for the service was $246 which is less than the copayment amount of $325. Therefore, only $246 was charged 
as the copayment amount. 
 You have been asked to pay a $246 copayment for the outpatient hospital services. The outpatient hospital 
services falls within the Outpatient Surgery and Other Medical 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 outpatient hospital services provided on January 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a duplex scan (ultrasound) of the head 
provided on January 19, 2022. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that the test should be considered non-
radiologic with a $20 copayment. 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 $125 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay a $125 copayment for the 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 reduce 
the copayment for a duplex scan (ultrasound) of the head provided on January 19, 2022.