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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services 
 
You asked the Plan to pre-approve SNF services. You say that you need to stay longer because you have been 
falling. The Plan denied your request. The Plan says this is not reasonable and necessary. The Plan also says 
that this does not meet Medicare criteria for SNF coverage under the Medicare Part A benefit. 
 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 pre-approve SNF services. Our reviewer says that 
this does not meet criteria. Our physician reviewer found you do not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 18, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on August 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on  
February 1, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this service would not have been 
needed if the testing you originally received had been accurate. The Plan denied your request. The Plan says 
the copayment applied was 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 $165 
copayment for Medicare-covered in-network radiological diagnostic services, not including X-rays, performed 
in a physicians office or at a free-standing facility (such as a radiology center or medical clinic).  You have been asked to pay $105.35 for an ultrasound, which is less than your $165 copayment. 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 provided on February 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on February 16, 
2022. 
 
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 an appropriate modifier was not billed with this edit. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on February 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
thorax provided on February 14, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that these services were always covered 
in the past. 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 $175 
copayment for each advanced radiology service, such as CT scans.  
 
You have been asked to pay $140.55, which is less than the $175 copayment for the CT scan. The CT scan 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 tomography (CT) scan of the thorax provided on 
February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive hearing test performed on 
January 11, 2022. 
 
You asked the Plan to waive the copayment for the hearing test. You say that you should not be billed twice for 
the same visit. 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 $15 
copayment for each diagnostic hearing exam to treat disease and conditions of the ears.  
 
You have been asked to pay a $15 copayment for the hearing test. Please note that the comprehensive test is 
more in-depth and goes beyond the scope of a routine exam. The hearing test falls within the Hearing 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 a comprehensive hearing test 
performed on January 11, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department services provided on January 9, 2022, and 
February 8, 2022. 
 
You asked the Plan to pay for the emergency department services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to make 
a determination within the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's limited case file submitted to us includes no citation to a 
specific rule upon which this denial was based. There was no analysis provided by the Plan as to what rule was 
applied and why the services you rendered fit within that rule. There is no documentation that shows you are 
not certified with Medicare. Without this information, we cannot determine if the Plan's denial was appropriate. 
The burden is on the Plan to support why its denial is appropriate. The minimal information the Plan provided 
in the case file it submitted to us does not substantiate its denial. Therefore, we decided that the Plan has to pay 
for the emergency department services provided on January 9, 2022, and February 8, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 records do not document that the 
enrollee has adequate iron stores with an iron level of 17 micrograms/dL, a serum ferritin level of 33 ng/mL 
and a transferrin saturation level of five percent on June 17, 2022. The Retacrit is therefore 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 Retacrit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for bevacizumab injections provided on 
January 11, 2022, and February 1, 2022. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you should not be charges for the 
chemotherapy services. The Plan denied your request. The Plan says the correct coinsurance was 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 Part B chemotherapy drugs. 
 
Drug Allowed Amount 20% Coinsurance 
Bevacizumab  January 11, 2022 $1,047.38 $209.48 
 $4,189.52 $837.90 
Bevacizumab  February 1, 2022 $1,011.78 $202.36 
 $4,047.12 $809.42 
Total:  $2,059.16 You have been asked to pay $2,059.16, which is 20% of the allowed amount for the injections. The injections 
fall within the Medicare Part B Prescription Drugs 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 for bevacizumab injections provided on January 11, 2022, and February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided from 
January 26, 2022, to March 8, 2022. 
 
You asked the Plan to waive the copayments for specialist office visits. You say that you cannot afford these 
copayments so they should be waived. The Plan denied your request. The Plan says the copayments applied are 
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 $40 
copayment for medical care or surgery services in a specialty physician's office.  
 
 
 
 You have been asked to pay a total of $120 (3 visits x $40) copayment for the specialist office visits. Specialist 
office visits fall 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 copayments for specialist office visits provided from January 26, 2022, to 
March 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
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 bilateral knee pain due 
to osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc, Supartz FX, Durolane, 
Monovisc or Synvisc-One. The records do not show that the required drugs would be contraindicated or less 
effective; therefore, Euflexxa 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 Euflexxa.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mental health telehealth services provided 
on October 12, 2021. 
 
You asked the Plan to waive the copayment for the mental health telehealth services. You say that you were not 
aware of the copayment at the time of service. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for mental health services.  
 
You have been asked to pay a $40 copayment for the mental health telehealth services. The mental health 
telehealth services fall within the Outpatient Mental Health Care benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for mental health telehealth services provided on October 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an x-ray provided on February 4, 2022. 
 
You asked the Plan to waive the coinsurance for an x-ray. You say that you believe the charges should be paid 
in full by your Personal Injury Protection coverage. The Plan denied your request. The Plan says the 
coinsurance applied was 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 20% 
coinsurance for Medicare covered outpatient x-rays. The allowed amount of the claim is $88.75, resulting in a 
coinsurance amount of $17.75 ($88.75 x 20%). 
 
You have been asked to pay $17.75 for an x-ray. An x-ray 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 coinsurance for 
an x-ray provided on February 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on December 8, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the copayment applied was 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 $150 
copayment for CT scans. The allowed amount of your claim is $116.21. 
 
You have been asked to pay $116.21 for your approved CT scan, which is less than your $150 copayment. The 
medical necessity of your scan was not in question. CT scans 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 a 
CT scan provided on December 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
provided on February 11, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you feel this copayment should be covered. 
The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $275 
copayment for advanced imaging services.  
 
You have been asked to pay $275 copayment for an MRI. MRIs 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 
MRI provided on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on  
January 27, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that this service would not have been 
needed if the testing you originally received had been accurate. The Plan denied your request. The Plan says 
the copayment applied was 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 $10 
copayment for Medically-necessary medical or surgical services furnished in an in-network physicians office.  
 
 You have been asked to pay a $10 copayment for an office visit. An 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 office visit provided on January 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
October 8, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you paid the copayment for 
surgery and did not know about the additional copayment for physical therapy. 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 $195 
copayment for services provided at a hospital outpatient facility.  
 
You have been asked to pay $179.90, which is less than the $195 copayment for the PT services. The PT 
services fall within the Outpatient Hospital 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 physical therapy (PT) services provided on October 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from March 9, 2022, to March 30, 2022. 
 
You asked the Plan to waive the copayments for the PT services. You say that you were advised there would be 
no copayments. 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 each therapy visit.  
 
The file shows you had a total of 7 visits for physical therapy from March 9, 2022, to March 30, 2022. 
Therefore, you have been asked to pay a $20 copayment for each visit for the PT services, for a total of $140 
($20 copayment x 7 visits = $140). The PT services fall within the Outpatient Rehabilitation 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 copayments for physical therapy (PT) services provided from 
March 9, 2022, to March 30, 2022.