Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit provided on May 19, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy visit. You say that you are an in-network provider. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services.  The record shows the provider is out-of-network. Therefore, we decided that the Plan does not have to pay for 
the psychotherapy visit provided on May 19, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you do not have the strength to hold yourself 
up and you're afraid of falling. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra infusions to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON Fasenra infusions. You say that this treatment is medically 
necessary. The Plan denied your request. The Plan says there are two in-network infusion centers closer to the 
enrollee's home address than the requested provider. As there is no network deficiency for this service, the 
request for OON care is correctly denied. 
 
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 
Fasenra infusions to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Omentectomy represented by code 49255 provided on 
May 4, 2021. 
 
You asked the Plan to pay for code 49255. 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 as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 49255 
is a column II code to column I codes 43332, 43631 and 43832. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Omentectomy 
represented by code 49255 provided on May 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. You say that this drug is part of the preferred regimen for the 
enrollee's condition. The Plan denied your request. The Plan says the denial of authorization for this drug is 
correct, because this drug is not being requested for a medically-accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Tecentriq. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Tecentriq. Our physician reviewer found 
the Food & Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's 
clinical situation. This requested use of Tecentriq is not supported by one of the major drug compendia or by 
clinical research appearing in a Medicare-approved medical journal.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Tecentriq.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit you had with an internal 
medicine physician to have a mole removed on May 26, 2021. 
 
You asked the Plan to waive the deductible for the office visit. You say that you were charged but you were 
told you would have no out-of-pocket expenses. The Plan denied your request. The Plan says you were charged 
this deductible correctly. 
 
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 203 deductible which applies to medical services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 203 deductible which 
applies to the medical services you received. This cost sharing is a contractual obligation that had not been met 
at the time the office visit was received on May 26, 2021. Therefore, we decided that the Plan does not have to 
waive the deductible for the office visit you had with an internal medicine physician to have a mole removed 
on May 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
April 21, 2021, to April 27, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were admitted due 
to having the coronavirus and you were told that the government would not be paying the charges. The Plan 
denied your request. The Plan says the claims were processed correctly and you are being charged the correct 
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 $390 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from April 21, 2021, to April 27, 2021. Therefore, you are responsible to pay a $390 copayment for days 1-5 (April 21, 2021, to April 25, 2021). The total amount you owe is: $390 
(copayment) x 5 (inpatient days) = $1,950.  
 
You have been asked to pay the total copayment amount of $1,950 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from April 21, 2021, to April 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested treatment is a medical necessity for you. 
The Plan denied your request. The Plan says step therapy rules for the requested drug have 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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Zoledronic Acid before they will approve the requested drug. The enrollee has not tried 
and failed the required drug. There is no documentation indicating that the Plan?s required drug 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network laser therapy provided from May 11, 2021 to 
June 1, 2021. 
 
You asked the Plan to pay for out of network services. You say that these services should be covered by the 
Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 out of network laser therapy provided from May 
11, 2021 to June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the punch biopsy of skin (11104, 11105) and the office visit 
(99203) rendered by the out-of-network (OON) provider on June 25, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal.  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 the punch biopsy of skin 
(11104, 11105) and the office visit (99203) rendered by the out-of-network (OON) provider on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 21, 2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this was your annual visit for 
your urology condition. The Plan denied your request. The Plan says the claims were processed correctly and 
you are being charged the correct 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 specialist visits. 
 
The medical records show that you had a specialist visit on June 21, 2021. Therefore, you are responsible to 
pay the $40 copayment.   
 You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor?s 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 a specialist visit provided on June 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on January 
20, 2021. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that after your mammogram, 
you were advised you should do more tests.  You didn't realize that they were referring to an ultrasound.  If you 
had known about the copayment, you would have said no. The Plan denied your request. The Plan says you 
were charged this copayment correctly.  The Plan says that because the allowed amount for this service 
($93.87) is less than your copayment obligation, you are responsible for the full allowed 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 $100 
copayment for ultrasounds.  
 You have been asked to pay a $100 copayment for the breast ultrasound. 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 breast ultrasound you had on January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wheelchair you rented on June 10, 
2021. 
 
You asked the Plan to waive the coinsurance for the wheelchair. You say that you should not owe this 
coinsurance because the wheelchair was returned. The Plan denied your request. The Plan says you were 
charged this coinsurance correctly.  The records show that you did not return the wheelchair until June 14, 
2021. 
 
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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the wheelchair. The wheelchair falls within the durable 
medical equipment benefit category. Medicare pays for rented durable medical equipment on a monthly basis.  
The monthly rental is not pro-rated if you return the item partway through the month.  Because you had this 
item in your possession for four days, you were appropriately assessed one month's coinsurance. 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 the wheelchair you rented on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 21, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were unaware a prior authorization was needed, 
and this service was medically necessary. The Plan denied your request. The Plan says no prior authorization 
was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on June 21, 2021, by an out-of-network 
(OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee is doing physical therapy (PT), 
occupational therapy (OT) and speech therapy (ST) at the SNF and she is responding very well. The Plan 
denied your request. The Plan says the enrollee has made minimal progress with therapy and is at baseline level 
of function. The enrollee's needs can be met at a lower level of care. 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 the SNF services. Our reviewer says 
that daily skilled services are not medically necessary. Our physician reviewer found from a nursing 
perspective, the enrollee received enteral nutrition and medications. The enrollee had stable vital signs. She 
tolerated a trach collar. Regarding rehabilitation services, the enrollee received PT, ST and OT in the SNF. By 
the dates in question, the enrollee was at maximal assist/dependent level for functional mobility including 
needing a mechanical lift for transfers. The enrollee required varying assist with activities of daily living. She 
had ongoing cognitive-linguistic and swallowing impairment. There are 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. As a practical matter, this 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you received 
in your primary care provider's (PCP) office on June 1, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that this was your annual physical and you 
have never been charged for your physical before. The Plan denied your request. The Plan says you were not 
charged a copayment for the physical itself.  You were charged a copayment for the ECG, which is not part of 
the physical. 
 
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 diagnostic tests in a PCP's office.   
You have been asked to pay a $10 copayment for the ECG. Your Evidence of Coverage explicitly states that 
you are responsible for separate cost sharing for diagnostic testing performed during an annual physical exam. 
That is why the ECG falls within the diagnostic tests in a PCP's office 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 electrocardiogram (ECG) you received in your primary care 
provider's (PCP) office on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive medicine evaluation provided on April 28, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the preventive medicine evaluation. You say that the service was medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the preventive medicine evaluation provided on 
April 28, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visit you had with a Physician's 
Assistant at an urgent care facility on June 8, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you told this provider that you 
thought you had some kind of infection due to past symptoms.  You stated that the provider refused to do a 
urinalysis and blood work and instead instructed you to go to your primary care doctor. You do not think you 
should have to pay a copayment for this service. The Plan denied your request. The Plan says you were charged 
this copayment correctly. 
 
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 $65 
copayment for urgent care services.  
 Records show that you went to the urgent care clinic on this date and received services.  According to your 
contract, you have a $65 copayment for urgent care services.  However, the Plan has chosen to only charge you 
the lesser $35 copayment that applies to specialist services.  Because you did receive services, a copayment is 
applied correctly.  The copayment applies regardless of your satisfaction with the services. 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 visit you had with a Physician's Assistant at an urgent care 
facility on June 8, 2021.