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

 
We decided that the Plan does not have to waive the deductible for laboratory work provided by a network 
physician from September 17, 2021, to September 28, 2021 
 
You asked the Plan to waive the deductible for the laboratory work. You say that you had met your deductible 
earlier in the year.  The Plan denied your request. The Plan says you have been asked to pay the correct cost-
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $600 deductible which applies to in-network Medicare covered 
laboratory services.  
 
The laboratory work you asked the Plan to waive the deductible for falls within the Outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $600 deductible which applies to in-network Medicare covered 
laboratory services. The record shows the deductible had not been met at the time the claims were processed. This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received 
on September 17, 2021 to September 28, 2021. Therefore, we decided that the Plan does not have to waive the 
deductible for laboratory work provided by a network physician from September 17, 2021, to September 28, 
2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional inpatient psychiatric hospitalization services 
from April 14, 2020, forward. 
 
You asked the Plan to pre-approve additional inpatient psychiatric hospitalization services. You say that 
additional inpatient psychiatric hospitalization services are medically necessary. The Plan denied your request. 
The Plan says continued inpatient psychiatric care is not medically necessary and you can be managed as an 
outpatient. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 additional inpatient psychiatric 
hospitalization services. Our reviewer says that additional inpatient psychiatric hospitalization services are not 
medically necessary. Our physician reviewer found it was not expected you would improve in a reasonable 
period of time for the dates in question as you did not have suicidal or homicidal ideation, auditory or visual 
hallucinations. You were compliant with treatment while not showing any acute threats to safety. It does not 
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care 
rather than a lower level of care beyond April 14, 2022, as you did not have dangerousness to self or others and 
were compliant with your treatment. It does not appear that active treatment was taking place beyond April 14, 
2022.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional inpatient psychiatric hospitalization services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve additional inpatient psychiatric 
hospitalization services from April 14, 2020, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213), removal of fluid from, or injection 
into, a major joint (defined as a shoulder, hip, knee, or subacromial bursa), or both aspiration and injection of 
the same joint (20610), and an influenza virus vaccine (G0008, 90686) provided on October 13, 2021, by an 
out-of-network (OON) provider.  
You asked the Plan to pay for an office visit, removal of fluid from, or injection into, a major joint (defined as a 
shoulder, hip, knee, or subacromial bursa), or both aspiration and injection of the same joint (20610), and an 
influenza virus vaccine. You say that you want a back-dated authorization for the member on date of service 
October 13, 2021, for claims to be paid for. You also say that the failure to obtain an authorization was due to a 
misunderstanding of benefits for this particular plan, and the patient was a walk-in new patient at the time of 
service. The Plan denied your request. The Plan says this Plan does not allow for backdated authorizations, as 
an authorization must be in place prior to services being rendered. 
 
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 (99213), removal of fluid from, or 
injection into, a major joint (defined as a shoulder, hip, knee, or subacromial bursa), or both aspiration and 
injection of the same joint (20610), and an influenza virus vaccine (G0008, 90686) provided on October 13, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiovascular stress test on November 
30, 2021. 
 
You asked the Plan to waive the copayment for the cardiovascular stress test. You say that you were advised 
that there was no copay for a stress test. 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 $40 
copayment for Routine Radiology.  
 
 
 You have been asked to pay a $40 copayment for the cardiovascular stress test. The cardiovascular stress test 
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 the cardiovascular stress test on November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically reasonable and necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are payable by Medicare. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from October 10, 2021 to October 20, 2021. 
  
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled need. 
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found there 
are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from October 10, 2021 to 
October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are payable by Medicare. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, zoledronic acid. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative, zoledronic acid. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred 
step one alternative. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and copayment for an injection and outpatient 
services provided on July 12, 2021. 
 
You asked the Plan to waive the coinsurance and copayment for an injection and outpatient services. You say 
that you were told your insurance would fully cover these services. The Plan denied your request. The Plan 
says the services were covered, and the proper coinsurance and copayment were applied. 
 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 each Medicare-covered Part B drug. Additionally, for the administration of that drug, you will 
pay the cost-sharing that applies to primary care provider services, specialist services, or outpatient hospital 
services depending on where you received drug administration or infusion services. The total amount allowed 
for the injection was $954.56 with a coinsurance of $190.91 ($954.56 total amount x 20% coinsurance). 
 
Your contract with the Plan also clearly says that you must pay a $350 copayment for Medicare-covered 
surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other 
facility charges and physician or surgical charges. The total amount allowed for the outpatient services was 
$65.33 which is less than the $350 copayment. Therefore, only $65.33 was charged as the copayment. 
 
You have been asked to pay a $190.91 coinsurance for an injection and a $65.33 copayment for outpatient 
services. The injection falls within the Medicare Part B Prescription Drugs benefit category. The outpatient 
services falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
and copayment for an injection and outpatient services provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient office visit (99203) provided 
on January 28, 2021. 
 
You asked the Plan to waive the copayment for an outpatient office visit. You say that you had a colonoscopy 
on February 8, 2021, and on January 28, 2021, you had a pre-operative appointment. You also say it was not a 
medical visit, and a few weeks later you got a bill for $40. The Plan denied your request. The Plan says you 
were 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 per specialist visit.  
 
You have been asked to pay a $40 copayment for an outpatient office visit. An outpatient office 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 an outpatient office visit (99203) provided on January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140) 
and first intraoral periapical x-ray (D0220) provided on December 3, 2021 by an out-of-network (OON) 
provider. 
 
  You asked the Plan to pay more for the problem focused limited oral evaluation and first intraoral periapical x-
ray. You say that the Plan only paid a fraction, and you never recouped the $1,000.00 that you were promised 
the Plan offers. You also say that you are appealing your cost share of $39.53. The Plan denied your request. 
The Plan says this claim was processed correctly with a $39.53 cost share, as the treating provider is OON. The 
Plan also says that you may be responsible for balances up to the dentist's charge. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the $100 
deductible which you must pay out-of-pocket before the Plan will pay their share for your covered dental 
services. The amount of $39.53 that you are being charged is applied toward your deductible. Therefore, we 
decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on December 3, 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 inpatient rehabilitation facility (IRF) admission to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON IRF admission. You say that you have no other place to go. The Plan 
denied your request. The Plan says out-of-network care is not covered and network facilities are available. 
 
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 
inpatient rehabilitation facility (IRF) admission 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 minimally invasive percutaneous sacroiliac (SI) fusion 
(27279). 
 
You asked the Plan to pre-approve the outpatient surgery. You say that say the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the clinical value 
and effectiveness of a minimally invasive percutaneous sacroiliac fusion in the setting of bilateral SI joint 
arthritis and multilevel lumbar spinal stenosis have not been demonstrated in the peer reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the outpatient surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of the back pain is not well defined. There is lumbar degeneration but there 
is no sacroiliac instability. 
 
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 outpatient surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve minimally invasive percutaneous sacroiliac (SI) fusion (27279).