Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says that Keytruda is not medically necessary and reasonable. 
 
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 Keytruda. Our reviewer says that 
Keytruda is medically necessary for you. Our physician reviewer found Keytruda is FDA-approved for patients 
who had a response to immunotherapy and have been more than 6 months out, as they have shown response to 
immunotherapy. Its use is supported by medical literature and the documentation supports that Keytruda is safe 
and effective and otherwise reasonable and necessary 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to a LTACH is medically 
necessary. The Plan denied your request. The Plan says LTACH admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the enrollee was admitted for planned redo sternotomy and replacement 
of ascending aorta with root replacement.  The record indicates that the enrollee developed acute respiratory 
failure and acute kidney injury and still requires ongoing acute care services.   The enrollee continues to receive 
acute care services and these have not been denied.  The medical record does not indicate that the enrollee 
requires services that she is not currently receiving but that would be available at the LTACH facility.  The 
elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bladder irrigation (51700) and ultrasound measurement of 
post-voiding residual urine (51798) provided on November 3, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for a bladder irrigation and ultrasound measurement of post-voiding residual urine. 
You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The 
Plan says rules for payment for out-of-network care have not been met. 
 
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 bladder irrigation (51700) and ultrasound 
measurement of post-voiding residual urine (51798) provided on November 3, 2021, by an out-of-network 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 6, 
2021, to September 7, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this claim should be paid. The Plan 
denied your request. The Plan says inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was a 53 year old female with a history of chronic atrial fibrillation, 
hypertension, and end-stage renal disease on dialysis. On the Friday before the hospitalization, she had only 1 
liter ultrafiltration done. Over the weekend, she had increased shortness of breath that prompted visit to the 
emergency room on September 6, 2021. She had a computed tomographic angiogram that showed evidence of 
pulmonary edema.  Her last dialysis was on September 3, 2021. She had no respiratory distress or edema to 
bilateral lower extremities. She was admitted as Inpatient with impression of hyperkalemia and shortness of 
breath. The plan was to admit her to telemetry, rule out Acute Coronary Syndrome, monitor for Atrial 
Fibrillation, and administer hemodialysis. She was discharged to home in less than 24 hours. The review has 
determined that the record did not show that at the time of inpatient admission the admitting physician 
reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from September 6, 2021, to September 
7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90837) provided on  
January 10, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for psychotherapy services. You say that you have an established relationship with 
the provider at issue and do not want to change therapists. The Plan denied your request. The Plan says rules 
for payment for out-of-network care have not been met. 
 
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 psychotherapy services (90837) provided on 
January 10, 2022, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an mri (73721) provided on November 1, 
2021. 
 
You asked the Plan to waive the deductible for the mri. You say that the services should be covered The Plan 
denied your request. The Plan says the deductible applied correctly based on the services provided. 
 
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 $1,250 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,250 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
the mri was received on November 1, 2021. Therefore, we decided that the Plan does not have to waive the 
deductible for an mri (73721) provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on  
August 30, 2021. 
 
You asked the Plan to waive the deductible for the laboratory services. You say that you did not see anything in 
the EOC saying you had to meet the deductible. The Plan denied your request. The Plan says the correct 
amount was applied to your deductible. 
 
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 $500 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $500 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the laboratory services was received on 
August 30, 2021. Therefore, we decided that the Plan does not have to waive the deductible for laboratory 
services provided on August 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided by an outpatient 
therapy assistant on October 4, 2021. 
 
You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-
contract providers at the preferred provider rate when services are not available from preferred providers in the 
service area. You say that in-network benefits should be honored, and the claim processed for payment. The 
Plan denied your request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant 
(OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, 
because they do not meet the qualifications of a therapist.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy 
services provided by an outpatient therapy assistant on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (36415, 80053, 80061, 82306) provided 
on October 19, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for laboratory services. You say that the services at issue were a necessity for the 
enrollee's care. The Plan denied your request. The Plan says rules for payment for out-of-network care have not 
been met. 
 
 
 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 laboratory services (36415, 80053, 80061, 82306) 
provided on October 19, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) 
provided September 1, 2021. 
 
You asked the Plan to pay for the orthoses. You say that please find enclosed for review, the physician's order, 
notes and supporting documents. After review of the enrollee's records and the pertinent LCD, you find that the element of medical necessity is met. The Plan denied your request. The Plan says the records provided do not 
support medical necessity of the provided orthoses. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 knee orthosis (L1833) and suspension 
sleeve (L2397) provided September 1, 2021. have been met. no treatment records were provided and there is no 
evidence of an established relationship between the enrollee and the ordering physician. The Plan made 
multiple attempts to obtain medical records from the provider without success.. Therefore, we decided that the 
Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) provided September 1, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for the hospital outpatient surgery provided on 
October 4, 2021. 
 
You asked the Plan to lower the copayment for the hospital outpatient surgery. You say that you were 
recommended to get the procedure at a hospital facility, so the copayment should be lowered. The Plan denied 
your request. The Plan says the copayment amount charged 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 a $300 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.  
 
 You have been asked to pay a $300 copayment for hospital outpatient surgery. Hospital outpatient surgery falls 
within the Outpatient Surgery and Other Medical 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 lower the copayment for the hospital 
outpatient surgery provided on October 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a magnetic resonance imaging (MRI) of 
lower extremities provided on November 1, 2021. 
 
You asked the Plan to waive the deductible for the MRI. You say that you were unable to complete the MRI 
due to loud noises you were hearing. The Plan denied your request. The Plan says the correct amount was 
applied to your deductible. 
 
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 $1,250 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. Please note that while the test was not completed, the 
service was still rendered.  The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,250 deductible which 
applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the 
time the MRI was received on November 1, 2021. Therefore, we decided that the Plan does not have to waive 
the deductible for a magnetic resonance imaging (MRI) of lower extremities provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 these 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 the laboratory services rendered on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology services rendered on  
September 16, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC of radiology services when furnished in a different payment locality than the TC. 
 
 
 
 We looked at the file and Medicare rules. The file shows that the services were not billed with modifier -26 to 
allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for the molecular 
pathology services rendered on September 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a surgery provided on October 18, 2021. 
 
You asked the Plan to waive the coinsurance for the surgery. You say that the services should be covered. The 
Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided. 
 
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 Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  You have been asked to pay a $1,490.30 coinsurance for the surgery which is less than the standard 20% based 
on the allowed amount. 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 a surgery provided on October 
18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray examination of the spine, 
lumbosacral. 
 
You asked the Plan to waive the copayment for an x-ray examination of the spine, lumbosacral. You say that if 
you had this x-ray done on the date of your annual physical visit on October 15, 2021, you would have had no 
copayment. You also say that because of the coronavirus (COVID-19), you were unable to make a second 
appointment on the day of your annual physical, so you had to set this appointment up for October 22, 2021, 
and because this x-ray was performed on a day separate from your annual physical, you are being charged this 
$10 copayment. The Plan denied your request. The Plan says you were charged the correct cost sharing 
amount. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment per day for x-rays.  
 
You have been asked to pay a $10 copayment for an x-ray examination of the spine, lumbosacral. An x-ray 
examination of the spine, lumbosacral 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 x-ray examination of the 
spine, lumbosacral.