Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry visit provided on February 13, 
2023. 
 
You asked the Plan to waive the copayment for podiatry visit. You say that you say that the provider is 
charging you for a debridement of nail(s) that was not performed by the doctor. 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 $50 
copayment for podiatry services. 
 
You have been asked to pay a $50 copayment for podiatry visit. This item/service falls within the podiatry 
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 podiatry visit provided on 
February 13, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eyelea 2MG/0.05ML syringe (J0178). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says they did not receive clinical documentation supporting why the 
enrollee is not able to meet step therapy guidelines for Eyelea. The Plan states there was no indication showing: 
a history of prior treatment with Avastin (bevacizumab) resulting in a substandard response to therapy or any 
documentation of intolerance or adverse event to treatment with Avastin (bevacizumab). The Plan states there 
was no rationale that treatment with Avastin (bevacizumab) is not clinically appropriate for the enrollee. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found there is documentation of use of bevacizumab on May 8, 2023, but there is no indication of an adverse 
effect or failure of the treatment. Based on the medical records provided and the Medicare-approved major 
drug compendia there is no indication that the Plan's required drug would likely be less effective and/or likely 
have adverse effects 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Eyelea 2MG/0.05ML syringe (J0178).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on January 12, 2023. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance. This item/service falls within the ambulance 
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 ambulance provided on 
January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home evaluation visit provided on February 22, 2023. 
 
You asked the Plan to pay for home evaluation visit. You say that it is the responsibility of the facility to obtain 
authorization. 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 home evaluation visit 
provided on February 22, 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 you require rehabilitation to regain strength and 
mobility after hospitalization. The Plan denied your request. The Plan says the IRF services requested 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 that you do 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 or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on February 13, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that the provider told you the specimen needed to be 
sent to this laboratory because this is what they specialize in. 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 laboratory testing 
provided on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit evaluation provided on February 15, 2023. 
 
You asked the Plan to pay for the home visit evaluation. 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 the home visit 
evaluation provided on February 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by an 
in-network provider from December 8, 2022, to December 10, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you would like the 
copayment to be lower. 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 $275 
copayment per day, days 1-6, for each in-network Medicare-covered inpatient stay. 
 
 You have been asked to pay a $275 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital stay provided by an in-network provider from December 8, 2022, to December 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services (11042) provided on October 1, 2021. 
 
You asked the Plan to pay for the podiatry services. The Plan denied your request. The Plan says this claim was 
not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the podiatry services was not filed until December 30, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the podiatry services (11042) provided on October 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for out-of-network ambulance rides provided on 
September 13, 2022, and October 19, 2022. 
 
You asked the Plan to waive the cost for out-of-network ambulance rides. You say that you have 8 ambulance 
rides per year at no cost to you, you should not owe this much. 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. Your 
contract with the Plan says that there is a $400 deductible and a $240 copayment which applies to ambulance 
services. You have been asked to pay the allowed amount of $12.21 which is less than the $240 copayment for 
an out-of-network ambulance ($400 deductible + $12.21 copayment = $412.21 total due). 
 
The item or service you asked the Plan to waive the cost for falls within the ambulance services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 
deductible and a $240 copayment which applies to ambulance services.  This cost sharing is a contractual obligation that had not been met at the time out-of-network ambulance rides 
was received on September 13, 2022, to October 19, 2022. Therefore, we decided that the Plan does not have to 
waive the cost for out-of-network ambulance rides provided on September 13, 2022, and October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visits provided on February 10, 2023, to March 2, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a home visits. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says the service was not authorized. 
 
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 home visits provided on February 10, 2023, to 
March 2, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiographic event provided on December 12, 2022, 
by an out-of-network (OON) provider.  
 
 You asked the Plan to pay for electrocardiographic event. You say that you are requesting reconsideration 
stating medical necessity. The Plan denied your request. The Plan says the enrollee must receive their care from 
a network provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the 
enrollee receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
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 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 electrocardiographic event provided on December 
12, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on January 24, 2023. 
 
You asked the Plan to pay for the wound care supplies. 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 the wound care supplies 
provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each facet joint injection provided on 
January 04, 2023, to January 20, 2023. 
 
You asked the Plan to waive the copayment for each facet joint injection. You say that you do not think you 
should be responsible for the cost share. 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 $370 
copayment for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital.  
You have been asked to pay a $370 copayment for each facet joint injection. This item/service falls within the 
other outpatient procedures and services, including, but not limited to, diagnostic and therapeutic endoscopy, 
and outpatient surgery performed in an outpatient hospital 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. The total amount you owe is $740 ($370 
copayment x 2 services = $740). Therefore, we decided that the Plan does not have to waive the copayment for 
each facet joint injection provided on January 04, 2023, to January 20, 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 LTACH is more appropriate. The Plan 
denied your request. The Plan says the enrollee's needs can be met in an alternate level of care such as an acute 
rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting, or home care. 
 
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 that the acute hospital can provide for all the enrollees present inpatient care needs 
and the enrollee is receiving an appropriate level of care in the present setting. The provided records do not 
explain what care services will be provided in the LTACH that are not available in the present hospital setting. The health plan has not stated that continued care in the short-term acute hospital will not be covered. The 
enrollee does not appear stable for transfer with new acute deep vein thromboses on anticoagulation, recent 
bleeding issues, recurrent mucus plugging issues and lack of a secure feeding tube (as of the time of this 
review). Continued care in the short-term acute hospital is appropriate until the enrollee is stable to transfer to a 
lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance urinary tract infection (UTI) test (87481, 
87500, 87511, 87640, 87653, 87798, 87801) provided September 1, 2022.  
 
You asked the Plan to pay for the laboratory service. You say that the enrollee's physician ordered the 
medically necessary Guidance UTI test as the enrollee's history of chronic urinary tract symptoms that failed to 
resolve with standard treatment.  The Plan denied your request. The Plan says Under Medicare guidelines, this 
request is not medically necessary because your records show the Guidance urinary tract infection test is not 
FDA or MolDX approved. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Guidance UTI testing is not medically reasonable and necessary in this case because 
the Guidance urinary tract infection test is not Food and Drug Administration (FDA) or Molecular Diagnostic 
(MolDX) approved.  
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guidance urinary tract infection (UTI) test (87481, 87500, 87511, 87640, 87653, 
87798, 87801) provided September 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six office visits and treatment with an out-of-network 
provider. 
 
You asked the Plan to pre-approve the referral. You say that the enrollee's condition has a more aggressive 
histology and clinical course and needs to be treated promptly by an experienced high-volume endocrine 
surgeon. The Plan denied your request. The Plan says the requested treatment can 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 referral. Our reviewer says that the requested referral is not medically 
reasonable or necessary. Our physician reviewer found that the record indicates that the enrollee has medullary 
thyroid cancer and requires thyroidectomy.  The plan has indicated that in-network providers are available and 
capable of providing the services required by the enrollee. The record provided does not document unique 
circumstances about the enrollee's condition that make it medically necessary for her to see the requested out-
of-network provider. 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 the referral 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 referral. Therefore, we decided that the Plan does 
not have to pre-approve six office visits and treatment with an out-of-network provider.