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

 
We decided that the Plan does not have to waive the coinsurance for medical supplies and a CT scan provided 
on February 7, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to waive the coinsurance for medical supplies and a CT scan. You say that the scan was a 
necessary test, and the facility was the only place you could go. 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 50% 
coinsurance for each OON medical supply, which includes chemical agents used in certain diagnostic 
procedures and 40% coinsurance for OON radiological diagnostic services, not including x-rays.  You have been asked to pay $1,099.46 for medical supplies and a CT scan performed by an OON provider. 
This total includes $9.06, which is 50% of the allowed amount for a chemical agent used during the CT scan 
($18.11 allowed x 50% = $9.06), and $1,090.40, which is 40% of the allowed amount for a CT scan ($2,726 
allowed x 40% = $1,090.40). These items/services fall within the outpatient diagnostic tests benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for medical supplies and a CT scan provided on February 7, 
2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myriad MyRisk Update Test and the Integrated BReast 
CAncer gene (BRCA) Analysis testing. 
 
You asked the Plan to pre-approve Myriad MyRisk Update Test and the Integrated BRCA Analysis testing. 
You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that NGS as a diagnostic laboratory test is covered under 
certain circumstances. 
 
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 Myriad MyRisk Update Test and the Integrated BRCA Analysis testing. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the review indicates that you are a 66-year-old female with no personal history of 
breast, ovarian, or pancreatic cancer. There is no documentation of any signs or symptoms of cancer. The 
review has determined that you do not meet the coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Myriad MyRisk Update Test and the Integrated BRCA Analysis testing have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Myriad MyRisk Update Test 
and the Integrated BReast CAncer gene (BRCA) Analysis testing.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 3, 2023, 
to March 31, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you thought there would be no 
copayment for 30 days. 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 $0 
copayment for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care.  You have been asked to pay $1,592.75 for a SNF stay. This total is less than the standard copayment for a SNF 
stay because your maximum out-of-pocket was met with the processing of this claim ($196 per day x 9 days = 
$1,764). This item/service falls within the 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 SNF stay provided from March 3, 2023, to March 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the enrollee is in pain and the denial 
should be reconsidered. The Plan denied your request. The Plan says non-thermal modalities for facet joint 
denervation is not medically necessary. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that cooled radiofrequency ablation does not meet the coverage criteria of the LCD. 
Only regular radiofrequency ablation is considered evidence-based therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
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 the enrollee has ongoing medical needs 
requiring another 4-6 weeks of care and rehabilitation for the enrollee to have a meaningful recovery. The Plan 
denied your request. The Plan says the enrollee is receiving the appropriate inpatient care and does not require 
transfer to a LTACH. 
 
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 the enrollee appears to be improving and should only require short-term additional 
acute care services that can safely be provided at the current facility until more stable and appropriate for 
transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current 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 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Neulasta. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that Neulasta is not 
medically necessary.  
 
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 drug. Our reviewer says that 
Neulasta is medically necessary. Our physician reviewer found that the requested use of Neulasta is FDA-
approved. Neulasta is also safe and effective and otherwise reasonable and necessary 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve 
Neulasta.  
 
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 reduce the copayment for an IRF stay provided from April 3, 2023, 
to April 12, 2023. 
 
You asked the Plan to reduce the copayment for an IRF stay. You say that you disagree with the copayment 
applied for the inpatient facility visit. 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 $225 
copayment per day for days 1 to 7 for Medicare-covered hospital care each time you are admitted and $0 
copayment for additional days for inpatient hospital care.  
 
You have been asked to pay $1,500 copayment for an IRF stay. This total is less than the standard copayment 
for an IRF admission because your maximum out-of-pocket was met with the processing of this claim ($225 
per day x 7 days = $1,575). This item/service falls within the for 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 reduce the copayment for an IRF stay provided from April 3, 2023, to April 12, 2023.
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 the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not 
require transfer to a LTACH. 
 
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 the enrollee appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental cleaning (D1110), bitewing x-rays-four 
radiographic images (D0274), and the comprehensive oral evaluation (D0150) provided on April 26, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the dental cleaning (D1110), bitewing  
x-rays-four radiographic images (D0274), and the comprehensive oral evaluation (D0150) provided on  
April 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the pelvis 
(72197) to be rendered by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the out-of-network services. You say that your prostate-specific antigen 
(PSA) levels have increased over past two months. The Plan denied your request. The Plan says they are unable 
to identify any scope of services requested that cannot be provided in-network.  
 
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found there is no 
documentation explaining the medical necessity for the indicated exam to be done at an out of network facility. 
A valid reason could be the generation or field strength of the magnet, Et cetera, at the out of network facility, 
but no reason aside from personal preference is given. The medical necessity for out of network exam has not 
been established in the records submitted. 
 
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 out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the pelvis (72197) to be 
rendered by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomographic angiography (CTA) of the chest 
provided on April 10, 2023.  
 
You asked the Plan to pay for the CTA. You say that you received an authorization letter for the services. The 
Plan denied your request. The Plan says prior authorization was not obtained. The authorization letter approved 
a different procedure than what was performed. 
 
Medicare rules say that plans can require enrollees to get prior authorization for certain services. The contract 
with the Plan says that the Plan has to pay for services only in cases which have been authorized prior to the 
services being rendered. 
 
In this case, 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 
computed tomographic angiography (CTA) of the chest provided on April 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 1, 2023, 
to March 28, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were required to stay in the 
facility an additional week due to a medical condition. 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 $0 
copayment for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $1,372 for a SNF stay ($196 per day x 7 days = $1,372). This item/service falls 
within the 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 SNF stay provided 
from March 1, 2023, to March 28, 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 enrollee needs rehab services as they are unable 
to breathe on their own. The Plan denied your request. The Plan says the IRF services you are requesting do not 
meet the requirements for approval. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in 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: 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 enrollee requires and would benefit from 
intensive inpatient rehab hospitalization with daily physician visits and examinations. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for 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 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140), resin-
based composite-one surface, anterior (D2330), and the resin-based composites-one surface, posterior  
(D2391 x 2) provided on April 3, 2023 and April 20, 2023. 
 
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 these services are not covered under the 
supplemental dental policy.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among 
those covered under this benefit.   
 
 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation-problem focused 
(D0140), resin-based composite-one surface, anterior (D2330), and the resin-based composites-one surface, 
posterior (D2391 x 2) provided on April 3, 2023 and April 20, 2023.