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

 
We decided that the Plan does not have to pre-approve Ontruzant for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs. 
 
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 the drug. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the record 
indicates that the enrollee has breast cancer. The requested medication is a new start. The provided records do 
not indicate that the enrollee has tried and failed the plan's preferred step one alternatives. 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 alternatives. The elements of the coverage criteria are not satisfied. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ontruzant for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavior health services provided on January 20, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the behavior health services. You say that your physicians were the only 
providers allowed into the facility and the enrollee could not choose an in-network provider. 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 behavior health services provided on January 
20, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the pelvis provided on 
December 6, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you have had this test three times 
in 2021 and the wrong billing code was used. 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 $105 
copayment for radiological diagnostic services, including an ultrasound.  
 
The medical record shows the correct billing code was used for the ultrasound you received on December 6, 
2021. You have been asked to pay the allowed amount of $81.23, which is less than the $105 copayment for an ultrasound. An ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound of the pelvis 
provided on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 22, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went to the urgent care 
center for a sore throat after testing positive for COVID-19. You also say that you barely received an exam, and 
no treatment was provided. 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 $50 
copayment for an urgent care visit.  
 
 The medical record shows you had an urgent care visit on January 22, 2022. You have been asked to pay a $50 
copayment for an urgent care visit. An urgent care visit falls within the Urgently Needed 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 urgent care visit provided on January 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 6, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the member stated they saw this physician because 
they provide holistic care, which was beneficial due to their issues. The Plan denied your request. The Plan 
says based on the review of additional information received, it was determined that a new physician visit was 
rendered on October 6, 2021, with an out-of-network provider. The Plan also says that a referral from the 
health plan was not obtained for this 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 October 6, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for Part B drugs (codes J1100 and J2270) provided on 
December 7, 2021. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that the medicine made you sick and 
that you should not have to pay for it. The Plan denied your request. The Plan says that 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.  
 
The Plan says you must pay 20% coinsurance for Part B drugs (codes J1100 and J2270). According to 
Medicare, codes J1100 and J2270 are considered packaged codes and are not separately payable. Therefore, we 
decided that the Plan has to waive the coinsurance for Part B drugs (codes J1100 and J2270) provided on 
December 7, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic shoe insert (A5500) and sales tax (S9999), 
provided on May 20, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the shoe insert and sales tax. You say that the item should be covered. The Plan 
denied your request. The Plan says no authorization was obtained prior to the purchase. 
 
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 diabetic shoe insert (A5500) and sales tax 
(S9999), provided on May 20, 2021 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 care beyond what is 
provided in a skilled nursing facility. The Plan denied your request. The Plan says the denial of authorization 
for LTACH care is correct. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
current acute care hospital where the enrollee is receiving 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 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: 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 the enrollee's chance to return home and maintain 
living at home will be significantly reduced if she is not approved for IRF care. The Plan denied your request. 
The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower level of care 
such as at a skilled nursing facility, at home with home health services or in a long-term care 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 while the enrollee has a need for physical and/or occupational therapy, there 
is no documentation of a need for an intensive rehabilitation program such as 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on December 17, 
2021. 
 
You asked the Plan to waive the copayment for ultrasound. You say that the ultrasound should have been 
covered according to the summary of benefits. The Plan denied your request. The Plan says coinsurance 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 $110 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-
network physicians office or at a free-standing facility (such as a radiology center or medical clinic).   
You have been asked to pay $78.60, which is less than the standard $110 copayment for an ultrasound. The 
ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for ultrasound provided on December 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bendeka and Rituximab. 
 
You asked the Plan to pre-approve Bendeka and Rituximab. You say that these drugs are medically reasonable 
and necessary. The Plan denied your request. The Plan says the documentation does not support that member 
has a relapse of follicular lymphoma. 
 
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 Bendeka and Rituximab. Our reviewer 
says that the requested drugs are not medically reasonable and necessary for the enrollee's condition. Our 
physician reviewer found the enrollee has a diagnosis of Follicular lymphoma grade I, lymph nodes of multiple 
sites. BCL-6 is moderately to strongly expressed. On July 7, 2021, it was documented that the enrollee needed 
to start Bendeka and Rituximab, with 4 cycles planned. The plan on March 9, 2022, was to continue Bendeka 
and Rituximab. Both Bendeka and Rituximab are FDA-approved for the treatment of B-cell lymphoma. 
However, the documentation does not support that the requested drugs are safe and effective and otherwise reasonable and necessary for this enrollee as there has been progression of the enrollee's follicular lymphoma 
while receiving Bendeka and Rituximab. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Bendeka and Rituximab have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Bendeka and Rituximab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for selective catheter placement provided to the enrollee on July 
12, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 36215 is "Selective catheter placement, arterial system; 
each first order thoracic or brachiocephalic branch, within a vascular family." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the procedure report documents 
"Attention was then turned toward the arterial inflow.  Selective catheterization of the brachial artery was 
performed and an arteriorgram obtained. This was done to evaluate for poor flow." Per CPT guidelines "For the 
purposed of reporting dialysis access maintenance services, the arterial inflow to the dialysis circuit is considered a separate vessel.  If a more proximal arterial inflow problem separate from the peripheral dialysis 
segment is suspected, additional catheter placement and imaging required for adequate evaluation of the artery 
may be separately reported.  If a catheter is selectively advanced from the dialysis circuit puncture beyond the 
peri-anastomotic segment into the inflow artery, an additional catheterization code may be reported." In this 
case, procedure report does not include enough documentation to confirm catheter was advanced beyond peri-
anastomotic segment into arterial inflow, and therefore this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for selective catheter placement provided to the enrollee on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says services are available in-network and not medically 
necessary. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extracapsular cataract removal with insertion of 
intraocular lens prosthesis to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve extracapsular cataract removal with insertion of intraocular lens prosthesis. 
You say that your denial of my request was written about a provider who does not exist, and that is the address 
who are your primary physicians. You also say that your situation is not the regular ophthalmologist referral, 
but the surgery center is in network. The Plan denied your request. The Plan says the records received do not 
indicate that you are in need of specialized services that are not available in the network. The Plan also says 
that there are in-network providers within your provider directory. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
extracapsular cataract removal with insertion of intraocular lens prosthesis to be provided by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Foot Orthotics to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve Foot Orthotics. 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 it was 
determined these services can be received in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
Foot Orthotics to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you would like to have a consult with 
an OON provider because of the type of surgery they perform and there is no in-network provider that uses the 
same procedure. The Plan denied your request. The Plan says there are in-network providers available to have a 
consultation with for the type of surgery that the enrollee needs. Also, the requested service is for an office visit 
consultation and not the actual surgery itself. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.