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

 
We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the request for Keytruda is not medically necessary. 
 
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. Our reviewer says that the 
requested drug, Keytruda, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
reviewer found that 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. Therefore, the reviewer found that the requested drug is not medically 
reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (pembrolizumab) (J9271).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
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. The patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can be safely administered at the current facility until more appropriate for a lower level of care in order to 
continue physical and occupational therapy. The patient does not require services at the LTACH that are not 
already available at the current facility. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for LTACH services. 
 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the application of a multi-layer wound 
compression system below the knee, including ankle and foot (29581), provided by an in-network provider 
from February 4, 2022, to February 28, 2022. 
 
You asked the Plan to waive the copayment for the application of compression bandages. You say that you 
should not be responsible for the copayment because the hospital is at fault. You say the hospital should take 
responsibility for failure to prescribe the proper medications to treat fluid buildup in your legs. As a result, you 
developed two large sores and had to return to the wound center. The Plan denied your request. The Plan says 
the copayment was applied correctly in accordance with your contract with the Plan. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for Medicare-covered surgery or other services provided at an outpatient hospital.  
 
You have been asked to pay a total of $971.18 in copayments for the application of compression bandages. The 
services at issue fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. The provider billed $745.50 for each service, but 
the Plan only allowed an amount of $138.74 for each service. Since the allowed amount is less than the 
contractually required copayment of $295, you are only responsible for the lesser amount of $138.74 per 
service. You received services on February 4, 2022; February 7, 2022; February 11, 2022; February 14, 2022; 
February 18, 2022; February 21, 2022; and February 28, 2022. See below for a breakdown of your cost-share. 
 
$138.74  7 services = $971.18 
 
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 application of a multi-layer wound compression system 
below the knee, including ankle and foot (29581), provided by an in-network provider from February 4, 2022, 
to February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for rehabilitation therapy visit, and an elbow 
brace provided on March 18, 2022. 
 
You asked the Plan to waive the cost share for rehab visit and an elbow brace. You say that the cost share is too 
high when you already pay a premium every month. The Plan denied your request. The Plan says the cost share 
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 $25 
copayment for therapy visit and 20% coinsurance for prosthetic devices.  
 
 
 You have been asked to pay a total of $70.60 for the therapy visit and brace. You have been asked to pay $25 
copayment for the rehab visit and $45.60 which is 20% of the allowed amount for an elbow brace. The allowed 
amount is $228(20% x $228 =- $45.60). The rehab visit falls within the Outpatient Rehabilitation Services 
benefit category.  The elbow brace falls within the Prosthetic Devices and Related 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 cost share for rehabilitation therapy visit, and an elbow brace provided on 
March 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) 
provided on December 22, 2020 
 
You asked the Plan to waive the copayment for the oxygen equipment. You say that the services should be 
covered as you disagree with the charges, were not made aware of them, and they accumulated over time. The 
Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Durable Medical Equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the oxygen equipment (allowed is $112.82 x 20% = 
$22.57). Oxygen equipment falls within the Durable Medical Equipment (DME) and related 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 Oxygen equipment (E0431, E1390) provided 
on December 22, 2020
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 22, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that since your doctor recommended it, 
it should be covered. 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 $20 
copayment for each Medicare-covered x-ray.  
 
You have been asked to pay $20 copayment for an ultrasound. Ultrasounds 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 an ultrasound provided on March 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) billed for date of service 
December 30, 2021. 
 
You asked the Plan to pay for critical care. You say that this service was reported correctly. The Plan denied 
your request. The Plan says this service is not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the record. Without this information, a time-based code like 99291 cannot be verified. 
Based on this information, we decided that Medicare rules for coverage of critical care have not been met. 
Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) billed for date of 
service December 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography, of the head or 
brain; without contrast material (70450) provided on February 7, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $225 
copayment for advanced imaging services.  
 
You have been asked to pay a $105.92 copayment for the advanced imaging service provided. This is the 
Plans allowed amount for this service which is less than the applicable copayment. 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 computed tomography, of the 
head or brain; without contrast material (70450) provided on February 7, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the $250 copayment for a colonoscopy performed on April 1, 2022. 
 
You asked the Plan to waive the $250 copayment for a colonoscopy. You say that you should not be 
responsible to pay this because it was a screening colonoscopy, not a diagnostic colonoscopy. The Plan denied 
your request. The Plan says that the cost share has been applied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, per the EOC, there is no copayment applied to screening 
colonoscopies. You allege that this was a screening colonoscopy, not diagnostic. The Plan has not addressed 
your argument or forwarded medical records to verify what services were rendered on the date of service in 
question. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plans 
denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to 
waive the $250 copayment for a colonoscopy performed on April 1, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuropsychological testing services (96116, 96132, 96133, 
96136, 96137) provided on February 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network services. You say that these services were necessary and were 
referred by another provider. The Plan denied your request. The Plan says out-of-network care is only covered 
in certain limited circumstances. The requested services were not urgent or emergent and could have been 
performed by an in-network provider. In addition, the provider who referred these services was also not part of 
the Plan's network. 
 
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 neuropsychological testing services (96116, 
96132, 96133, 96136, 96137) provided on February 25, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten occupational therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says there must be an expectation that the condition will improve significantly in a 
reasonable and generally predictable period of time based on the physician's assessment of the patient's 
rehabilitation potential, after any needed consultation with the qualified occupational therapist. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found that the additional requested therapy is not generally accepted as specific and 
effective therapy for your condition beyond what was approved by the plan. The records do not  demonstrate 
that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or  by or under the supervision of a 
therapist. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 
You can transition to a home exercise program and do not require ongoing skilled therapy. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ten occupational therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 26, 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 diagnosis code was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
laterality for the diagnosis code. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 24, 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 request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 24, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 4, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sent the specimen to 
your laboratory to process, and you would like the claim 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 the laboratory services provided on March 4, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve daratumumab, 10MG and hyaluronidase-fihj injeciton 
(CPT code J9144) and diphenhydramine HCL, up to 50MG injection (CPT code J1200). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says using Darzalex Faspro with Velcade and Revlimid may not help to manage the 
enrollee's cancer. The Plan states it cannot be used as the enrollee's first treatment if they will not be getting 
healthy cells put into their body and it is not supported by criteria and is not medically necessary. 
 
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 regimen is for transplant eligible and this enrollee is stated as transplant ineligible. The use is not 
supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & 
Medicaid Services (CMS)-approved medical journal. 
 
 
 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 daratumumab, 10MG and hyaluronidase-fihj injeciton (CPT code J9144) and 
diphenhydramine HCL, up to 50MG injection (CPT code J1200).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided 
from February 27, 2022, to March 1, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you feel this should have been an 
inpatient stay. 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 emergency services.  
 
The records show that you were kept in the hospital under observation care. Therefore, you have been asked to 
pay a $40 copayment for the ER visit. 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 from February 27, 
2022, to March 1, 2022.