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

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from September 23, 2021, to October 14, 2021. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you should not be charged for the 1 
day over the 20-day limit. The Plan denied your request. The Plan says the proper copayment 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 $160 
copayment for Days 21-100: per day, per admission. From September 23, 2021, to October 14, 2021, the total 
amount of days was 22 days. The provider only billed for 21 days. Therefore, only 1 day was charged a $160 
copayment. 
 
  You have been asked to pay a $160 copayment for the SNF stay. The SNF stay falls within the Skilled nursing 
facility (SNF) 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 a skilled nursing 
facility (SNF) stay provided from September 23, 2021, to October 14, 2021.  
 
Your complaint about your experience with this provider 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 30, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were told the 
services would be covered but then received a bill showing that it was not. The Plan denied your request. The 
Plan says the service was covered, and the proper copayment 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 $25 
copayment for each covered specialist office visit.  
 
  You have been asked to pay a $25 copayment for the specialist office visit. The specialist 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 a specialist office visit provided on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 20, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that service was provided to the enrollee out of medical 
necessity. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider 
and there was no referral from an in-network provider or an approved 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on September 20, 2021, by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on August 9, 
2021. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that the visit was for an annual 
screening. 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 $110 
copayment for diagnostic radiology services, including ultrasounds.  
 
The file shows that the screening mammogram for the visit was covered, however the ultrasound was 
considered an additional test. Therefore, you have been asked to pay a $110 copayment for the breast 
ultrasound.  The breast 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 a breast ultrasound provided on 
August 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like reconsideration because the requested 
drug is medically necessary. The Plan denied your request. The Plan says the records must show what is being 
done in addition to the Prolia, calcium supplement, and vitamin D to reduce the risk of breaking bones. 
 
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 Prolia. Our reviewer says that the Food 
and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. Our 
physician reviewer found the Medicare approved drug compendia do not contain a supportive citation for the 
use of the requested drug in the enrollee's clinical situation.  The elements of the coverage criteria are not 
satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 16, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are a network provider, and the claim 
should be reprocessed for payment. The Plan denied your request. The Plan says the rendering provider is an 
out-of-network provider and there was no referral from an in-network provider or an approved authorization. 
Also, the service rendered was not urgent or emergent. 
 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 laboratory services provided on August 16, 
2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that Retacrit is medically necessary. The Plan denied your 
request. The Plan says that coverage criteria has not been met. 
 
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 Retacrit. Our reviewer says that 
Retacrit is medically necessary. Our physician reviewer found the enrollee is noted to have anemia and chronic 
kidney disease. The enrollee had low iron levels despite receiving oral iron therapy. The enrollee was 
subsequently given IV iron, which resulted in a ferritin level greater than 100, but the enrollees hemoglobin 
remained lower than 10g/dl.  s such, the requested Retacrit is shown to be medically necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have been met. Therefore, we decided that the Plan has to pre-approve 
Retacrit (Q5106).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the hospital bed. You say that you cannot transfer between your bed and 
wheelchair unless you have a bed that goes up and down. The Plan denied your request. The Plan says a total 
electric hospital bed is not covered under your plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs for the power wheelchair. 
 
You asked the Plan to pre-approve the repairs. You say that the wheelchair needs to be repaired. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the repairs have not been met. The cumulative cost of repairs is 
greater than the cost of replacement of the wheelchair. Medicare Guidance says cost of repair should not be 
more than cost of replacement. Therefore, we decided that the Plan does not have to pre-approve repairs for the 
power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on November 12, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a psychotherapy visit. You say that as per credentialing status, the provider is 
enrolled and in-network with the Plan. You also say that services are payable, and the Plan is responsible to pay 
the provider. The Plan denied your request. The Plan says the rendering provider is a non-participating 
provider, and there is no referring provider involved in these services. The Plan also says that they did not 
authorize any services for this provider. 
 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 a psychotherapy visit provided on November 12, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thoracic surgery visit (99214, 99204) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the thoracic surgery visit. You say that the service is medically necessary. 
The Plan denied your request. The Plan says there are network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a thoracic 
surgery visit (99214, 99204) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the dental cleaning 
(D1110), the bitewing x-rays (D0274), the intraoral-periapical first radiographic image (D0220), and the 
periapical each additional radiographic image (D0230) rendered by the out-of-network (OON) provider on 
December 9, 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; therefore, the services are not covered under your contractual policy. 
 
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 periodic oral evaluation (D0120), the dental cleaning (D1110), the bitewing 
x-rays (D0274), the intraoral-periapical first radiographic image (D0220), and the periapical each additional 
radiographic image (D0230) rendered by the out-of-network (OON) provider on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 18, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that services provided to the enrollee should not 
need an authorization and would like the claim reprocessed for payment. The Plan denied your request. The 
Plan says the rendering provider is an out-of-network provider and there was no approved authorization. Also, 
the service provided was not urgent or emergent. 
 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 a home health visit provided on October 18, 2021, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for diagnostic eye exams provided from 
October 27, 2021, to November 12, 2021. 
 
You asked the Plan to waive the copayments for the eye exams. You say that you should not have copayments 
because they were post-op exams. 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 diagnostic tests in a physician's office.  
 
You have been asked to pay a $20 copayment for each of the eye exams, for a total of $40. The eye exams 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 copayments for diagnostic eye exams provided from October 27, 2021, to 
November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the triamcinolone injection (J3301), the therapeutic, 
prophylactic, or diagnostic injection (96372), and the office visit (99204) rendered by the out-of-network 
(OON) provider on December 7, 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 triamcinolone injection (J3301), the therapeutic, prophylactic, or diagnostic 
injection (96372), and the office visit (99204) rendered by the out-of-network (OON) provider on  
December 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found while the enrollee may benefit 
from physical therapy and occupational therapy, the enrollee does not need intensive therapies, consisting of at 
least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. The enrollee's rehab needs can be safely provided at a lower intensity and alternate setting. IRF admission 
is not medically necessary based on medical stability and lack of medical complexity and lack of acute rehab 
nursing needs. The documentation does not support the necessity for admission to an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on December 
17, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you do not remember being 
seen that day. 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 $65 
copayment for urgent care services.  
 
 
 The record shows that you were seen on December 17, 2021, for a suture check. Therefore, you have been 
asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the Urgently Needed 
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 an urgent care visit 
provided on December 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271, J9395). 
 
You asked the Plan to pre-approve the Keytruda. You say that Keytruda is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 the Keytruda. Our reviewer says that 
this drug is not medically necessary. Our physician reviewer found although the enrollee has progressed 
following prior treatment, she still has satisfactory alternative treatment options such as CDK4/6 inhibitors and 
Alpelisib given PIK3CA mutation. 
 
 
 
 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 Keytruda have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda (J9271, J9395).