Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive $178.60 of the coinsurance for an MRI contrast agent. We decided that 
the Plan does not have to waive $163.61 of the coinsurance for an MRI contrast agent.  
 
You asked the Plan to waive the coinsurance for an MRI provided on December 12, 2022.. You say that you 
reached your maximum out-of-pocket and the claim should be paid at 100%. The Plan says that this cost 
sharing was charged correctly. 
 
We decided that the Plan has to waive $178.60 of the coinsurance applied for an MRI contrast agent.  
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). The Plan applied this cost-sharing to the lines for 
gadoterate meglumine, which is an imaging contrast material, and did not apply cost-sharing to the MRI itself. 
Your contract with the Plan clearly says that you must pay 20% coinsurance for imaging medical supplies. The 
allowed amount for these supplies is $818/07, resulting in a coinsurance amount of $163.61.  
 
The Plan charged $342.21, which is more than 20% coinsurance for an MRI contrast agent. However, based on 
your contract with the Plan, you cannot be asked to pay more than $163.61, which is 20% coinsurance for an 
MRI contrast agent. Therefore, we decided that the Plan has to reduce your total cost-sharing for the MRI 
contrast agent by $178.60 from $342.21 to $163.61.  
 
We also decided that the Plan does not have to waive $163.61 of the coinsurance applied for an MRI 
contrast agent. 
 
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 medical supplies. The correct coinsurance that should be applied is $163.61, which is 20% of 
the allowed amount for the medical supplies. Therefore, we decided that the Plan does not have to waive 
$163.61 of the coinsurance for an MRI contrast agent. 
 
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 Opdivo. 
 
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 enrollee has esophageal cancer 
stated to be human epidermal growth factor receptor 2 (HER2) positive (+). The use of Opdivo is not supported 
for HER2+ disease. Only pembrolizumab is indicated for esophageal cancer that is HER2+ in combination with 
FOLFOX + Herceptin. The documentation does not support that the Opdivo is medically reasonable and 
necessary and safe and effective at this time. 
 
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 Opdivo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. You asked the Plan to pre-approve the requested device. You say that your fingers hurt with the needles. The 
Plan denied your request. The Plan says you do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation does not indicate that you use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
January 23, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
 
 
 
 
 
 We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 06, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on January 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pressure reducing air mattress. 
 You asked the Plan to pre-approve the requested mattress. You say that the enrollee's condition is not 
improving. The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that pressure reducing support surfaces are only 
covered under certain medical indications. 
 
We looked at the file and Medicare rules. The records indicate that the enrollees condition has healed. Based 
on this information, we decided that Medicare rules for coverage of the requested mattress have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a pressure reducing air mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment, coded E0675, billed for dates 
of service December 2, 2022, to December 27, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical literature substantiates the efficacy of 
the treatment. The Plan denied your request. The Plan says the service is not covered. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code E0675 is not supported. A pneumatic compression device is not covered when used as a 
preventative service. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the durable medical 
equipment, coded E0675, billed for dates of service December 2, 2022, to December 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October 1, 
2022, to October 6, 2022. 
 You asked the Plan to pay for SNF care. You say that the services are coverable under Medicare guidelines. 
The Plan denied your request. The Plan says the SNF services you are requesting do not meet the requirements 
for approval. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require skilled nursing or skilled therapy services that require 
the specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. The enrollee does 
not require skilled services on a daily basis. The enrollee does not require skilled services on an inpatient basis 
in a 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 care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from October 1, 2022, to October 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to be reimbursed of the maximum out-of-pocket for lab services and 
outpatient mental health on January 01, 2023, to April 07, 2023. 
 
 You asked the Plan to be reimbursed of the maximum out-of-pocket for lab services and outpatient mental 
health. You say that you are asking the plan to reconsider reimbursement of your maximum out-of-pocket 
(MOOP) medical expenses for the year to date. The Plan denied your request. The Plan says this cost sharing 
was charged 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 must 
pay a $10 copayment for each covered lab service performed in an outpatient facility department. Covered 
services include but are not limited to laboratory tests. You must pay a $40 copayment for each covered 
therapy visit. This applies to individual or group therapy. Covered services include mental health services 
provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse 
specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental health care professional as 
allowed under applicable state laws. There were two visits for lab services. 2 x $10 = $20. There were 7 visits 
for outpatient mental health. 7 x $40 = $280. For all services it's, $280 + $20 = $300. After review, it was 
found that you have only met $300 of your $4,200 maximum out-of-pocket (MOOP) and there is no 
overpayment due.  
 
You have been asked to pay a $300 maximum out-of-pocket for lab services and outpatient mental health. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies and 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 be reimbursed of the maximum out-of-pocket 
for lab services and outpatient mental health on January 01, 2023, to April 07, 2023.
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 services are medically necessary for the enrollee 
to receive the care and services needed to return to prior level of function and return home safely.  The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: 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 services are medically necessary for the enrollee 
to receive the care needed and return home with an increased independence. The Plan denied your request. The 
Plan says the enrollee should remain in the current setting and complete their course of treatment.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says the SNF services requested do not meet the 
requirements for approval.  
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. Although further rehabilitation services would be appropriate to improve function, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74019 billed for date of service February 13, 
2023. 
 You asked the Plan to pay for procedure code 74019. You say that you are requesting reconsideration of the 
denied service because procedure code 74019 was not bundled with any other procedure code performed on the 
same date of service. The Plan denied your request. The Plan says payment for code 74019 is bundled into 
payment for code 74022. 
 
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 74019 
is a column II code to column I code 74022. 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 procedure code 74019 billed for date of service February 13, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bathtub wall rail (E0241). 
 
You asked the Plan to pre-approve a bathtub wall rail. You say that you are at risk of falling and it is very 
slippery. The Plan denied your request. The Plan says the requested bathtub wall rail is not a covered benefit 
under Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that bathtub wall rails are not covered 
because they are not primarily medical in nature.  
 
While a bathtub wall rail 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 bathtub wall rail (E0241).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epoetin Alfa. 
 
You asked the Plan to pre-approve Epoetin Alfa. You say that you are appealing with supporting records.  The 
Plan denied your request. The Plan says the patient does not have the criteria for the use of medication 
requested. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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  Epoetin Alfa. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that Epoetin Alfa is not supported by one of the major drug compendia or by clinical research 
that appeals in a Centers for Medicare and Medicaid Services (CMS) 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  Epoetin Alfa have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Epoetin Alfa.