Persius/hicric huggingface dataset:
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 you need the IRF care because you had a knee 
replacement, but you require oxygen due to a complication. You say that a skilled nursing facility is not an 
option because they do not have respiratory staff. The Plan denied your request. The Plan says authorization 
denied because the IRF care is not medically necessary, and your needs can be met at a lower level of care such 
as a skilled nursing facility (SNF). 
 
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 medical problems are stable, there are no complex nursing or rehabilitation needs. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 November 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia. 
 
You asked the Plan to pre-approve Orencia. You say that the requested Orencia is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Stelara first. 
 
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 Orencia. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Stelara 
first before they will approve the requested drug. In this case, the enrollee has not tried and failed the required 
drug(s). There is no documentation provided indicating that the plans required drug(s) would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orencia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on August 9, 2021. 
 
You asked the Plan to waive the copayment for an office visit on August 9, 2021. You say that you are not 
responsible for a copayment because this was an annual wellness visit. The Plan denied your request. The Plan 
says enrollees pay a $10 copayment for Primary Care Physician visits. 
 
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 $10 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
You have been asked to pay a $10 copayment for an office visit. An office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. Please note: additional cost-
sharing may apply if other services are provided at the time of an annual wellness visit. Records submitted 
support that other services were provided. 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 office visit on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivered meals (S5170). 
 
You asked the Plan to pre-approve home delivered meals. The Plan denied your request. The Plan says home-
delivered meal service is not covered under your current benefits of coverage. 
 The Plan must follow Medicare rules. Medicare rules say that home delivery of meals may be offered as a 
supplemental benefit.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home delivered meals have not been met. Therefore, we decided that the Plan does not have to pre-
approve home delivered meals (S5170).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Ilumya. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found you have psoriasis and have previously been treated with topical triamcinolone, Otezla and Skyrizi. The 
documentation does not support that you have tried and failed Avsola or Remicade. The documentation does 
not support that Avsola or Remicade would be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulator. 
 
You asked the Plan to pre-approve a functional electrical stimulator. You say that this device is medically 
necessary. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a functional electrical stimulator have 
been met. In this case, no medical records were provided to document the medical necessity for the requested 
equipment. We sent out a request to the Plan to send additional requests to your provider for medical records. 
No documentation was returned to support the equipment despite the Plans multiple outreach attempts. 
Therefore, we decided that the Plan does not have to pre-approve a functional electrical stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 February 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 June 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for and pay for outpatient hospital surgery 
and self-administered drugs provided on March 4, 2022. 
 
You asked the Plan to waive the cost-sharing for and pay for outpatient surgery and self-administered drugs. 
You say that you thought the Plan would cover more than this amount. The Plan denied your request. The Plan 
says the cost-sharing amounts you are being charged are correct. The Plan also says that the denial of payment 
for self-administered drugs is correct, because these drugs are not covered by your Medicare Part B benefits. 
 
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 $450 
deductible and 10% coinsurance for in-network outpatient surgery at an outpatient hospital. At the time this 
claim was processed, $164.79 of the $450 in-network deductible had been met. The allowed amount of this 
claim is $4,895.15, resulting in a deductible amount of $285.21 because this met the $450 deductible for 2022. 
The remaining allowed amount of the claim is $4,609.94, resulting in a coinsurance amount of $460.99. 
Therefore, your total cost-sharing amount is $746.20. The rules also say that Medicare Part B generally does 
not pay for self-administered drugs. The self-administered drugs you received at this hospital visit are not 
among those covered by your Medicare Part B benefits. 
 
You have been asked to pay $450 deductible and 10% coinsurance for outpatient surgery. Outpatient surgery 
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 waive the cost-sharing for and pay 
for outpatient hospital surgery and self-administered drugs provided on March 4, 2022.  
 
Benefits for outpatient surgery and self-administered drugs may be available under Medicare Part D. Contact 
the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have lower your copayment for diagnostic testing provided on January 23, 
2022. 
 
You asked the Plan lower your copayment for diagnostic testing provided on January 23, 2022. You say that 
your copayment should only be $35 because you were never advised the diagnostic testing copayment had been 
changed for the 2022 plan year. The Plan denied your request. The Plan says enrollees pay a $75 copayment for 
diagnostic procedures and tests. 
 
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 $75 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $75 copayment for diagnostic testing. Diagnostic testing 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 
lower your copayment for diagnostic testing provided on January 23, 2022.   
Your complaint about not having been advised of plan changes is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and progressive lens provided on October 22, 
2021 by an out-of-network (OON) provider. 
 You asked the Plan to pay for the frames and progressive lens. You say that the customer service representative 
advised you could file a claim for reimbursement, but it was denied. You also say that this claim should be 
covered based on the information the customer service representative provided. The Plan denied your request. 
The Plan says these services were rendered by an OON provider. The Plan also says that your plan does not 
offer OON benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the services are rendered by a provider in the Plan's vision 
vendor network. 
 
We looked at the file and the Plan's rules. These services were rendered by an OON provider. The record also 
shows that when you contacted the Plan on October 5, 2021, you were advised that the facility you went to was 
not in-network with your plan. Based on this information, we decided that the Plan's rules for coverage of the 
frames and progressive lens have not been met. Therefore, we decided that the Plan does not have to pay for 
the frames and progressive lens provided on October 22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99152) provided on April 23, 
2021. 
 
You asked the Plan to pay for moderate sedation services (99152). The Plan denied your request. The Plan says 
procedure code 76937 has been overturned. The Plan also says that procedure code 99152 remains denied as 
the documentation submitted did not indicate the presence of an independent trained observer. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation does not 
support the presence of an independent trained observer as required by the CPT code billed. Based on this 
information, we decided that Medicare rules for coverage of moderate sedation services (99152) have not been 
met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99152) provided 
on April 23, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive your $300 copayment for surgery services performed on March 1, 2022. 
 
You asked the Plan to waive your $300 copayment for an EGD biopsy. You say that you didn't know about 
copayments. The Plan denied your request. The Plan says that you must pay a $300 copayment. 
 
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 does not say in clear and accurate terms 
how much you should expect to pay for Outpatient Surgery, Including Services Provided At Hospital 
Outpatient Facilities And Ambulatory Surgical Centers.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay $300 
copayment for Outpatient Surgery, Including Services Provided At Hospital Outpatient Facilities And 
Ambulatory Surgical Centers. The Plan contract does not clearly say how much enrollees must pay for 
Outpatient Surgery, Including Services Provided At Hospital Outpatient Facilities And Ambulatory Surgical 
Centers. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. 
Therefore, we decided that the Plan has to waive your $300 copayment for surgery services performed on 
March 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.