Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on March 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it was the hospital staff's responsibility to 
obtain authorization. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advance. 
 
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 nursing facility care provided on March 3, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 16, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says services from 
non-participating providers are not covered unless preauthorized. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on February 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have cerebral palsy and you have in home 
therapy twice a week but it is not helping. You say that therapy is only 45 minutes at a time and if you can get 
inpatient rehabilitation, you would be able to gain your mobility. The Plan denied your request. The Plan says 
admission was denied as not meeting inpatient rehabilitation admission and a lower level of care might be 
appropriate. Skilled nursing facility was offered. 
 
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 have a past medical history of cerebral palsy and lower extremity weakness 
and are living at home with ambulatory difficulties. Medical problems are stable. There are no complex nursing 
or rehabilitation needs. While you have a need for physical or occupational therapy, there is no documentation 
of a need for an intensive rehabilitation program. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health skilled nursing visits. 
 
You asked the Plan to pre-approve the home health skilled nursing visits. You say that the services are 
necessary. The Plan denied your request. The Plan says the enrollee's medical condition is stable, they have no 
recent hospitalizations, no medication changes and there are no skilled nursing needs identified. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 home health skilled nursing visits. 
Our physician reviewer found the medical records provided there is no documentation that skilled nursing 
services are required in this case. Provided records do not document any acute or unstable medical conditions 
or changes in medication or treatment which would necessitate skilled nursing visits. No medical visit notes 
from the enrollee's treating physician are provided documenting a need for skilled nursing services. Records do 
not document the need for intravenous medications, new tube feeding, or ostomy care or daily complex wound 
care or respiratory 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 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomographic angiography 
(CTA) provided on April 8, 2022. 
 
You asked the Plan to waive the copayment for the CTA. You say that the copayment would cause a financial 
hardship. 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 $325 
copayment for diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay $217.69, which is less than the $325 copayment for the CTA. The CTA falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a computed tomographic angiography (CTA) provided on April 8, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ear wax removal procedure performed 
on February 22, 2022. 
 
You asked the Plan to reduce the copayment for the wax removal. You say that the procedure was not surgical 
and you should only have a $20 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 $150 
copayment for surgery or services provided at an outpatient hospital.  
 
You have been asked to pay $59.39, which is less than the $150 copayment for the wax removal. The wax 
removal is considered a surgical procedure and falls within the Outpatient Surgery, Including 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 reduce the copayment for an ear wax removal procedure performed on February 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia 
with intolerance to oral iron supplementation. She has not tried and failed the Plan's required drugs, Infed and 
Venofer. The records do not show that the required drugs would be contraindicated or less effective; therefore, 
Injectafer is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmic diagnostic imaging provided on 
April 19, 2022. 
 
You asked the Plan to waive the copayment for the ophthalmic imaging. You say that you never paid for this 
test before. 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 $20 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $20 copayment for the ophthalmic imaging. The ophthalmic imaging 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 ophthalmic diagnostic imaging provided on April 19, 2022.
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 
abdomen provided on April 15, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that the copayment would cause a financial 
hardship. 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 $325 
copayment for diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $325 copayment for the MRI. The 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 abdomen provided on April 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of the inpatient 
rehabilitation admission. The Plan denied your request. The Plan says the records do not indicate the enrollee 
needs an intensive therapy program with multiple visits from a rehab doctor per week. The enrollee can receive 
the services needed in other settings, for example a skilled nursing facility, home with home health and home 
physical therapy. 
 
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 the enrollee was admitted for hyperglycemia and weakness. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Medically 
necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from February 4, 2021, to 
December 13, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you chose a PPO plan with out-of-
network coverage and would like to receive at least partial reimbursement. The Plan denied your request. The 
Plan says this provider is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy services provided from February 4, 2021, to December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on March 24, 
2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that you only had a PAP smear done. 
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 per day for laboratory tests that are not FIT tests.  
 
You have been asked to pay a $10 copayment for the lab services. The lab services 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 laboratory services provided on March 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram and a radiologic examination of the 
chest provided on February 16, 2022, and February 23, 2022. 
 
You asked the Plan to pay for an electrocardiogram and a radiologic examination of the chest. The Plan denied 
your request. The Plan says services from non-participating providers are not covered unless preauthorized. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an electrocardiogram and a radiologic examination of the chest 
provided on February 16, 2022, and February 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
March 2, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford 
the 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 $350 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $350 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 
ambulance transportation provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture adjustment (D5422) provided 
on April 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service is medically necessary. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 23, 2022, and 
March 28, 2022. Therefore, we decided that the Plan does not have to pay for a mandibular partial denture 
adjustment (D5422) provided on April 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 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 Aranesp. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found 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. 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) and pontic - 
porcelain/ceramic (D6245) for tooth #'s 28, 29 and 30. 
 
You asked the Plan to pre-approve crown and bridge. You say that the dental services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the dental services are not medically necessary. 
 
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. The Plan covers crown and 
bridge. when the services are medically necessary and reasonable.  
 
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 crown - porcelain/ceramic (D2740) and 
pontic - porcelain/ceramic (D6245) for tooth #'s 28, 29 and 30. Our physician reviewer found there is no 
indication that the member has attempted any type of removable appliance in the past and has a history of 
intolerance of such appliances. Although the treatment requested is reasonable, coverage criteria for fixed 
bridges is limited. Given the situation provided, the Plan criteria would not be met for the requested bridge. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crown and bridge. have not been met. Therefore, we decided that the Plan does 
not have to pre-approve crown - porcelain/ceramic (D2740) and pontic - porcelain/ceramic (D6245) for tooth 
#'s 28, 29 and 30.