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

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
prostate provided on February 3, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you are being charged $125 for a cancer 
screening service and there should be no 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 an in-network MRI. The Plan contract says that there is no cost share for an annual PSA test. The record shows that an MRI is not part of the prostate cancer screening. You have been asked to pay a $125 
copayment for an MRI. An MRI 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 magnetic resonance 
imaging (MRI) of the prostate provided on February 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of the pelvis with contrast dye 
(72193) provided by an in-network provider on January 28, 2022. 
 
You asked the Plan to waive the copayment for a pelvic CT scan. You say that you were told the CT scan was 
approved but you were not informed of any copayment. You also say that you paid for an entire exam despite 
the Plan denying approval for part of it. You asked the Plan to review the denial for potential refund. The Plan 
denied your request. The Plan says the cost-sharing was applied correctly, as outlined in the 2022 EOC.  
 
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 Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 You have been asked to pay a $225.97 copayment for a pelvic CT scan. Pelvic CT 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. You have been asked to pay a cost-
share amount which is less than the contractually required copayment of $325, therefore, you are only 
responsible for the lesser amount. 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 pelvis with contrast dye (72193) provided by an in-network provider on January 
28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Etoposide (CPT code J9181), Carboplatin (CPT code 
J9045), Tecentriq and (CPT code J9022). 
 
You asked the Plan to pre-approve the medication. You say that the regimen is medically necessary for the 
enrollee's cancer treatment. The Plan denied your request. The Plan says the enrollee has: newly diagnosed LS-
SCLC with negative brain scan results. The Plan states the documentation does not support that the enrollee 
has: extensive stage SCLC. The Plan states they found no Medicare compendia, NCCN compendium or 
guideline, nor phase 2 or greater literature support for this regimen, for the enrollee's clinical situation. 
 
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 the medication. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of limited stage small cell lung cancer. The Food 
and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition.  
The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Etoposide (CPT code J9181), Carboplatin (CPT code J9045), Tecentriq and (CPT code 
J9022).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a rehabilitation specialist visit provided on 
January 3, 2022. 
 
You asked the Plan to waive the copayment for a rehabilitation specialist 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 $30 
copayment for each rehabilitation specialist visit.  
 
You have been asked to pay a $30 copayment for a rehabilitation specialist visit. A rehabilitation specialist visit 
falls 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 
copayment for a rehabilitation specialist visit provided on January 3, 2022.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee was admitted with leg wounds and was found to be septic with acute kidney injury.  The record 
indicates that the enrollee has had a complicated course and requires ongoing acute care services. The enrollee 
continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 
facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for miscellaneous durable medical equipment (DME) (E1399)
provided on June 14, 2019.

You asked the Plan to pay for miscellaneous durable medical equipment. You say that you were unaware an
authorization was needed for the DME equipment. You say that you purchased the equipment based off of your
in-network provider. He suggested that you purchase the portable oxygen device. The Plan denied your request. The Plan says they cover all medically necessary DME covered by Medicare. The Plan says if their supplier in your area does not carry a particular brand or manufacturer, you may ask the Plan if they can special order it for you. The Plan states that a list of in-network suppliers is available on their website.

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 has network providers
available who can provide 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 miscellaneous durable medical equipment (DME)
(E1399) provided on June 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lenses provided on December 13, 2016.

You asked the Plan to pay for the contact lenses. The Plan denied your request. The Plan says the member sought treatment from an out-of-network provider which was not approved by their PCP or us. We verified there are in-network providers in the member's plan that could assist with purchasing contact lenses. We also verified that there were covered contact lenses in the power needed by the member.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by the Plan's vision provider. We looked at the file and the Plan's rules. The file shows that the contact lenses were not provided by the Plan's vision provider. Based on this information, we decided that the Plan's rules for coverage of the contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for contact lenses provided on December 13, 2016.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services provided on January 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON ophthalmology services. You say that you were not aware that 
authorization was needed. The Plan denied your request. The Plan says unauthorized, non-plan care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. 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 ophthalmology services provided on January 25, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home blood pressure monitor. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs the monitor due to other 
general symptoms and signs. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a home blood pressure monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz for shoulder pain (CPT code(s): J1030 and 
J7321). 
 
You asked the Plan to pre-approve the medication. You say that you have severe arthritis in your left and right 
shoulder, so you need the injection to relieve some pain. The Plan denied your request. The Plan says Supartz 
is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond 
adequately to conservative non-pharmacologic therapy and simple analgesics [e.g., acetaminophen]. The Plan 
states the request is for Supartz is for the treatment of shoulder pain and this is not a FDA indication and is not 
a covered diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 medication. Our physician reviewer 
found the record indicates that you have a diagnosis of arthritis bilateral shoulders. The Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for your condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in your clinical 
situation. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz for shoulder pain (CPT code(s): J1030 and J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next Blood Glucose test strips, a non-preferred 
brand. 
 You asked the Plan to pre-approve Contour Next Blood Glucose test strips. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee has not tried and failed 
the use of preferred brand diabetic test strips. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies. 
 
We looked at the file, the Plan's contract and Medicare rules. The services at issue are diabetic testing strips 
from a non-preferred brand. The services are available from the Plan's preferred brand. Therefore, we decided 
that the Plan does not have to pre-approve Contour Next Blood Glucose test strips, a non-preferred brand.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation SNF care from May 23, 2022, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy 
services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient 
basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation SNF care from May 23, 2022, forward.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
continued SNF care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found based on the documentation 
provided, the enrollee does not have documented skilled nursing needs. While the enrollee has a large sacral 
wound, the wound is chronic and only receiving every other day care. The enrollee does not have documented 
skilled therapy needs.  Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition.  The enrollees care needs, custodial and intermittent, can, as a 
practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from May 24, 2022, forward. 
 
You asked the Plan to pre-approve SNF care. You say that you do not believe you got enough physical therapy 
and do not feel strong enough to be discharged. The Plan denied your request. The Plan says the stay is not 
medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you no longer qualifies for SNF coverage. 
You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You 
appear to have reached a plateau in function. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at 
a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care from May 24, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth visit provided on December 8, 
2021. 
 
You asked the Plan to waive the copayment for a telehealth visit. You say that this was an annual physical via 
telehealth and should not have an office visit 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 $10 
copayment for a telehealth visit.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$10 copayment for a telehealth visit. A telehealth visit falls within the Physician/Practitioner Services, 
Including Doctors 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 
telehealth visit provided on December 8, 2021.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee was admitted with acute on chronic respiratory failure in the setting of heart failure. The record 
indicates that the enrollee continues to have bacteremia and requires acute care services. The enrollee continues 
to receive acute care services, and these have not been denied. The medical record does not indicate that the 
enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. 
The elements of the coverage rules are not satisfied.  The requested service cannot be recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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.