Persius/hicric huggingface dataset:
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 have complications from a liver transplant and 
need to be in a rehabilitation facility. The Plan denied your request. The Plan says criteria for admission to the 
IRF setting have not been met. Your medical needs are being met in the current acute 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on December 30, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON drug testing. You say that this was medically necessary testing. The 
Plan denied your request. The Plan says neither the lab nor the ordering provider is in-network with the Plan. 
No authorization was obtained for these OON services. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the drug testing provided on December 30, 2021, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on December 9, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you never received a denial letter, and you 
would like for the emergency services to be paid. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was 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 a specialist office visit provided on December 9, 
2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $40 copayment for physical therapy provided on 
December 29, 2021. 
 You asked the Plan to waive the $40 copayment for physical therapy provided on December 29, 2021. You say 
that you should not have to pay a $40 copayment because you had already reached your out-of-pocket 
maximum. The Plan denied your request. The Plan says the $40 copayment was correctly assessed. 
 
The Plan contract says your in-network maximum out-of-pocket amount is $4,400. The Plan contract also says 
your combined maximum out-of-pocket amount is $7, 550. At the time this claim was processed, your in-
network out-of-pocket maximum had been met; however, your combined out-of-pocket maximum had not been 
met. Services were rendered by an out-of-network provider. Therefore, you are responsible to pay your $40 
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 $40 
copayment for Outpatient Rehabilitation Services.  
 
You have been asked to pay a $40 copayment for physical therapy provided on December 29, 2021. Physical 
therapy falls within the Outpatient Rehabilitation Services benefit category. Please note, at the time this claim 
was processed your combined out-of-pocket maximum had not been met. 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 $40 copayment for physical therapy on December 29, 2021.  
 
Please note, the records indicate that you received physical therapy services from the physical therapy 
assistants that are under the supervision of the billing provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Medicare Part B drugs provided on 
October 15, 2021. 
 
You asked the Plan to waive the coinsurance for the Medicare Part B drugs. You say that you were never told 
that you would have to pay a copayment. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay $206.76 for the Medicare Part B drugs, which is 20% of the Plans allowed 
amount ($1,033.80). Medicare Part B drugs fall within the Medicare Part B Prescription Drugs 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 the Medicare Part B drugs provided on 
October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 5, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network and the member doesn't have OON 
benefits. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 5, 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH care for 
ventilator support with focus on weaning, complex wound care treatment, and complex critical care needs. The 
Plan denied your request. The Plan says there are no required medical services in the LTACH that you are not 
already receiving in your current approved hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. The health plan has approved ongoing care in the current acute care facility. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ontruzant. 
 
You asked the Plan to pre-approve Ontruzant. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the provider does not provide a rationale for use of the non-preferred product for 
safety or efficacy. 
 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 Ontruzant. Our reviewer says that 
Ontruzant is not medically reasonable and necessary. The patient has not tried and failed Herceptin, Herceptin 
Hylecta, Kanjinti or Trazimera. The plan's required drugs are not likely be less effective and/or likely have 
adverse effects for the enrollee as they are equally effective. Our physician reviewer found that your condition 
does not meet step therapy criteria for Ontruzant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ontruzant have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ontruzant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for photochemotherapy provided October 22, 
2021 to November 15, 2021. 
 
You asked the Plan to waive the copayment for photochemotherapy. You say that you received an invoice for 
$486. You say that you were told by the scheduling nurses before each visit that you would owe nothing. 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 $240 
copayment for Medicare-covered outpatient hospital services.  You have been asked to pay $486.72 which is less than the standard $240 copayment for photochemotherapy 
($81.12/visit x 6 = $486.72) Photochemotherapy 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 photochemotherapy provided October 22, 2021 
to November 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) scan on 
February 22, 2022. 
 
You asked the Plan to waive the copayment for a computerized tomography (CT) scan. You say that you would 
like to appeal the cost share. 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 $20 
copayment for a computerized tomography (CT) scan.  
 
You have been asked to pay a $20 copayment for a computerized tomography (CT) scan. a computerized 
tomography (CT) scan falls within the a computerized tomography (CT) scan 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 computerized tomography (CT) scan on February 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on September 2, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you are appealing based on a very 
confusing lengthy delay in finding out that you owe a high co-pay and not $35 for diagnostic procedures/tests 
or $0 for preventative tests. 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 $200 
copayment for diagnostic radiology services, including CT scans.  
 
 You have been asked to pay the allowed amount of $184.14, which is less than the $200 copayment for a CT 
scan. A CT 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 computed tomography (CT) scan of the 
abdomen and pelvis provided on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia service provided on December 14, 2021. 
 
You asked the Plan to pay for anesthesia. You say that there are no other claims to bundle this with, so it 
should be processed. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the required documentation was not submitted to support payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient 
information to determine whether payment is due and the amount of payment.  
 
We looked at the file and Medicare rules. No medical records were submitted to support the service billed on 
this claim. The Plan requested records, but none were submitted. Without this, you have not furnished 
sufficient information to support payment of this claim as it has been billed. Based on this information, we 
decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia service provided on December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82656, 83520, 83993, 89055) provided 
February 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 (82656, 83520, 83993, 89055) provided February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 7, 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 were not billed correctly. 
 
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 these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan of extremity veins including responses to 
compression and other maneuvers; unilateral or limited study (93971) provided on November 12, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a duplex scan. You say that you do not agree with the denial, and you are 
requesting reconsideration. The Plan denied your request. The Plan says the provider is not a network provider 
with the Plan. 
 
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. The records provided for review do not show that the services at issue were urgent or 
emergent. 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 duplex scan of extremity veins including responses to 
compression and other maneuvers; unilateral or limited study (93971) provided on November 12, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing rendered on April 15, 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 FANCC genetic testing is non-covered.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue was FANCC genetic testing. 
Therefore, we decided that the Plan does not have to pay for the FANCC genetic testing rendered on April 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visits with your Primary Care 
Physician (PCP) on June 24, 2021, to December 20, 2021. 
 
You asked the Plan to waive the copayments for your PCP. You say that when you applied you were told there 
was not a copayment for doctor's visits The Plan denied your request. The Plan says the cost-sharing amount 
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 $10 
copayment for each Medicare-covered visit with a PCP. There were 4 visits, resulting in a total copayment 
amount of $40.  
 
 
 
 You have been asked to pay a $10 copayment for each PCP visit. PCP visits fall within the in-network 
Medicare-covered visit. You have a $10 copayment for each Medicare-covered visit with an in-network PCP 
The allowed amount on this claim is $40. 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 office 
visits with your Primary Care Physician (PCP) on June 24, 2021, to December 20, 2021.