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

 
We decided that the Plan does not have to pre-approve Enyvio (vedolizumab) (J3380). 
 
You asked the Plan to pre-approve Enyvio. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Stelara. 
 
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 Enyvio. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. 
Therefore, the reviewer found that the step therapy criteria 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 Enyvio have not been met. Specifically, the file does not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative. Therefore, we decided that the Plan does 
not have to pre-approve Enyvio (vedolizumab) (J3380).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the enrollee has tried and failed oral iron tablets. 
The Plan denied your request. The Plan says the enrollee has not tried and failed the plan's preferred drugs, 
Ferrlecit, INFeD, or Venofer. 
 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 Feraheme. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed plan's preferred step one alternative. The record does not indicate 
that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. Therefore, the reviewer found that the step therapy criteria 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 Feraheme have not been met. Specifically, the file does not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative. Therefore, we decided that the Plan does 
not have to pre-approve Feraheme (Q0138).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Breo Ellipta. 
 
You asked the Plan to pre-approve Breo Ellipta. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
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 to pre-approve Breo Ellipta.  
 Benefits for Breo Ellipta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 are still having issues while in the hospital and 
you need further treatment and services before being released to go home or a lower level of care. The Plan 
denied your request. The Plan says authorization denied because IRF is not medically necessary, and your 
needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 your medical problems are stable, and there are no complex nursing or rehabilitation 
needs. The record shows you have a need for physical and/or occupational therapy, but there is no 
documentation of a need for an intensive rehabilitation 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for your inpatient hospital stay provided on 
June 22, 2021 to July 4, 2021. 
 
You asked the Plan to waive the copayment for your inpatient hospital stay. You say that the copayment should 
be waived. The Plan denied your request. The Plan says the copayment amount charged 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 $390 
copayment for each day for days 1-5 for Medicare-covered hospital care. $0 copayment for additional 
Medicare-covered days.  
 
 You have been asked to pay a $1950 copayment for your inpatient hospital stay, $390 was charged each day 
for days 1-5 ($390x5=$1950). An inpatient hospital stay falls within the Inpatient Hospital 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 your inpatient hospital stay provided on June 
22, 2021 to July 4, 2021.  
 
Your complaint about the Plans response time to approve your subsequent care is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient services provided on May 30, 
2021 to June 3, 2021. 
 
You asked the Plan to waive the copayment for inpatient services. You say that you are not liable for the 
charges. The Plan denied your request. The Plan says the copayment amount charged 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 $260 
copayment per day for days 1-4 for Medicare-covered inpatient hospital stays.  
 
 
 You have been asked to pay a $780 copayment for three days of inpatient services ($260x3). Inpatient services 
fall within the Inpatient Hospital 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 
inpatient services provided on May 30, 2021 to June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the laboratory services rendered on August 
31, 2021. 
 
You asked the Plan to waive the deductible for the laboratory services. You say that the laboratory services 
rendered were part of the annual wellness check-up. The Plan denied your request. The Plan says the deductible 
applied is correct. Your annual deductible is $500. This is the amount you have to pay out-of-pocket before 
they will pay their share for your covered medical services.  
 
  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 deductible, which applies to laboratory work.  
 
The laboratory work you asked the Plan to waive the deductible for falls within the benefit category 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $500 deductible which applies to laboratory work. At the time 
of claim processing, you had only met $219.97 of your $500 deductible. Until you have paid the deductible 
amount, you must pay the full cost for most of your covered services. This cost sharing is a contractual 
obligation that had not been met at the time the lab work was received on August 31, 2021. Therefore, we 
decided that the Plan does not have to waive the deductible for the laboratory services rendered on August 31, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a destruction of skin growth procedure 
provided on November 18, 2021. 
 
You asked the Plan to waive the copayment for a destruction of skin growth procedure. You say that you were 
told that this was a follow up from a previous surgery. You also say that the provider's office told you there 
would be no charge for this visit. 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 in-network specialist physician services.  
 
 The Plan confirmed that there is a global billing period of 10 days for the surgery performed on October 19, 
2021. The surgical services you received on November 18, 2021, are outside of the 10-day global period of the 
original date of service. You have been asked to pay a $40 copayment for a destruction of skin growth 
procedure. A destruction of skin growth 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 a destruction of skin growth procedure provided on November 18, 
2021.  
 
Your complaint about being told incorrect information is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Lumbar-sacral brace without rigid stays (L0628). 
 
You asked the Plan to pre-approve a Lumbar-sacral brace. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that items that do not meet the definition of a brace 
are statutorily noncovered, no benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Lumbar-sacral brace have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Lumbar-sacral brace without rigid stays (L0628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
November 15, 2021. 
 
You asked the Plan to waive the copayment for an ECG. You say that you have never been billed separately 
since being with this Plan. You want to know why you are being billed $10. 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 $10 
copayment for in-network outpatient diagnostic testing, including ECGs.  
 
The records show you had an ECG on November 15, 2021. An ECG (code 93005) is considered a separate 
payable service. You have been asked to pay a $10 copayment for an ECG. An ECG 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 an electrocardiogram (ECG) provided on November 15, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Outpatient hospital observation services on 
October 11, 2021 to October 13, 2021 
 
You asked the Plan to waive the copayment for Outpatient stay. You say that you believe the copayment should 
be $90. The Plan denied your request. The Plan says the copayment you are being charged 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 $150 
copayment for Outpatient hospital observation hours at an outpatient hospital facility.  
 
You have been asked to pay $150 copayment for Outpatient stay. Outpatient stay falls within the Outpatient 
hospital observation 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 hospital 
observation services on October 11, 2021 to October 13, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient treatment to be provided at the in-network 
benefit level by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient treatment. You say that there is no in-network physician that can 
treat or manage your condition. The Plan denied your request. The Plan says the denial of authorization for in-
network coverage is correct, because this provider is out-of-network with the Plan and you can be treated by an 
in-network specialist. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to receive care from out-of-network providers, but the share of costs for 
covered services may be higher. 
 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 at the in-network benefit level. You may choose to see this 
provider using your out-of-network benefits. Therefore, we decided that the Plan does not have to pre-approve 
outpatient treatment to be provided at the in-network benefit level 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 a colonoscopy (45385) provided on 
November 18, 2021. 
 
You asked the Plan to waive the copayment for the colonoscopy. 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 $350 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $350 copayment for a colonoscopy. Colonoscopies fall within the Outpatient 
hospital 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 a colonoscopy 
(45385) provided on November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient laboratory visit provided on 
February 26, 2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that the services should be covered as 
they were performed in an office setting. 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 $40 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $40 copayment for lab services. Lab services falls within the Outpatient hospital 
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 an outpatient laboratory 
visit provided on February 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance on October 15, 2021. 
 
You asked the Plan to waive the copayment for an ambulance. You say that you do not have money for this. 
The Plan denied your request. The Plan says the copayment you are being charged 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 $225 
copayment per one-way trip by ground transportation.  
 
You have been asked to pay a $225 copayment for an ambulance. An ambulance falls within the ambulance 
services benefit category 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 
ambulance on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on August 6, 
2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the services should be 
covered. 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 $15 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 You have been asked to pay a $15 copayment for two laboratory services, which is less than the standard $15 
each. the laboratory services 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 laboratory services provided on 
August 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on 
September 15, 2021. 
 
You asked the Plan to waive the copayment for the outpatient hospital visit. You say that the services should be 
covered as it was an office visit. 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 $110 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $110 copayment for an outpatient hospital visit. 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 outpatient hospital visit provided on September 15, 2021.