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

We decided that the Plan does not have to pre-approve bone marrow aspirate (20939).
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has
not been met.
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 bone marrow aspirate. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found bone marrow aspirate remains experimental in cases of spinal fusion. More research
is needed to show safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kevzara.
You asked the Plan to pre-approve Kevzara. You say that this is medically necessary. The Plan denied your
request. The Plan says coverage of this drug is the responsibility of Medicare Part D.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Kevzara.
Benefits for Kevzara may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee is not tolerating intensive level of therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not currently
require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple
therapies such as physical and occupational therapy but the documentation does not support that the patient's
functional status requires an intensive rehabilitation therapy program provided in an IRF. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 continued acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT angiography provided on March 6,
2020.
You asked the Plan to waive the copayment for the CT angiography. You say that the copayment is too much
for you to pay. You say that the copayment should be cut in half. The Plan denied your request. The Plan says
the copayment applied 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 $110
copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine, and stress
tests).
You have been asked to pay a $110 copayment for the CT angiography. The CT angiography 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 the CT angiography provided on March 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehab to return to a
normal quality of living. The Plan denied your request. The Plan says it is not reasonable to expect the enrollee
to need or be able to take part in 3 hours of therapy a day.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 physician reviewer found
that you are currently unable to ambulate. You are dependent for transfers, and at a dependent to maximum
assist level for activities of daily living. The complexity of your nursing, medical and rehabilitation needs do
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
patient's medical status does not currently require intensive physician and nursing oversight only in an IRF.
You may benefit from physical and occupational therapy, but the documentation does not support you're your
functional status can tolerate or requires an 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta (J2505).
You asked the Plan to pre-approve Neulasta. You say that the requested medication is necessary. The Plan
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has
not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Neulasta. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found Neulasta is indicated in enrollees with a
greater than 20% risk of neutropenic fever. This enrollee's regimen is not associated with a high or intermediate
risk of neutropenic fever even factoring in his age. He is not listed as having any prior chemotherapy other than
immunotherapy and comorbities and labs do not indicate increased risk. The service is not reasonable or
medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have
to pre-approve Neulasta (J2505).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel one.
You asked the Plan to pre-approve Gel one. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Gel one. Our reviewer says that the
requested drug is not medically necessary. Our physician reviewer found the documentation does not support
that the enrollee has tried and failed Orthovisc and Monovisc. The documentation does not support that the
plan's required drugs, Orthovisc and Monovisc would likely be less effective or likely to have adverse effects
than the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Gel one have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gel one.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on January 7,
2020.
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied
your request. The Plan says 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 Plan states that this provider is not a network
provider with the Plan and the services were not referred by a network provider or rendered in a participating
facility.
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 has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on
January 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on
February 5, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this was billed with an outpatient place of service (POS 22), and the service date falls between
the admission and discharge date of an inpatient confinement.
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, the CPT Code Manual definition of code 71045 is "Radiologic examination, chest."
We asked our coding 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 services. Our reviewer says that the
services at issue in this case were not coded correctly. Our coding reviewer found the documentation submitted
was reviewed, and supports a hospital admission on February 5, 2020. There is a more appropriate place of
service code for this claim.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for radiology services (CPT 71045) provided to the enrollee on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for remote evaluation of pacemaker provided on April 24, 2019,
July 24, 2019 and October 24, 2019.
You asked the Plan to pay for the remote evaluation of pacemaker. The Plan denied your request. The Plan says
there is not an approved authorization on file for seeing a provider that is not contracted with the Plan.
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 did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for remote evaluation of pacemaker provided on April 24, 2019, July
24, 2019 and October 24, 2019.
We decided that the Plan does not have to pay for remote evaluation of pacemaker provided on January 24,
2020.
You asked the Plan to pay for the remote evaluation of pacemaker. The Plan denied your request. The Plan says
the enrollee was enrolled in hospice on January 24, 2020 and the claim needs to be submitted directly to
Medicare for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit on January 24, 2020. The record shows proof of hospice
election from December 19, 2019 to August 14, 2020. Therefore, we decided that the Plan does not have to pay
for remote evaluation of pacemaker provided on January 24, 2020.
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 a continuous glucose monitor. You say that you cannot check your glucose
by yourself. The Plan denied your request. The Plan says criteria for a CGM is not met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The record shows you do not test four or more times a day and you
are not insulin treated. Based on this information, we decided that Medicare rules for coverage of a continuous
glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a
continuous glucose monitor.
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 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 IRF admission is covered only when it is medically reasonable and necessary as described above. 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 medically necessary. Our physician reviewer found the you were admitted to the hospital on July 11, 2020 after a fall. You had no fractures and were treated with pain medication. You are walking 10 feet with a rolling walker with minimum assistance. You need assistance with transfers and activities of daily living. You are medically stable and have no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 3, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you reached your maximum out-of-pocket amount on February 26, 2020. You say you would like the bill corrected. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each specialist visit. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows that as of March 16, 2020, you had met $2,794.85 of your 2020 maximum out-of-pocket amount. Please note, the Explanation of Benefits you submitted confirms that you met your 2019 maximum out-of-pocket amount which was processed by February 26, 2020.
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 specialist office visit provided on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ice machine.
You asked the Plan to pre-approve the requested device. You say that the machine is very helpful for your
recovery. The Plan denied your request. The Plan says there is inadequate evidence to show that a cryotherapy
machine is better than standard cold packs after knee surgery.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file, and Medicare rules. The requested cold pad with pump is considered not medically
necessary. Based on this information, we decided that Medicare rules for coverage have not been met.
Therefore, we decided that the Plan does not have to pre-approve an ice machine.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF service. You say that the enrollee needs assistance with mobility
and other activities of daily living. The Plan denied your request. The Plan says enrollee does not meet
Medicare criteria for SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the SNF service. Our reviewer says that
daily skilled services are not medically necessary. Our physician reviewer found that from a nursing
perspective, the enrollee received oral and inhaled medications. The enrollee had stable vital signs. She was
diagnosed with pneumonia. Regarding rehabilitation services, the enrollee received physical therapy (PT) and
occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a contact guard to minimal
assist level with functional mobility including gait to 15 feet with a rolling walker. The enrollee required
varying assist with activities of daily living. Our physician reviewer found that there are no identifiable skilled
nursing service needs. Although there are identifiable skilled therapy service needs, the enrollee does not
require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF service have not been met. Therefore, we decided that the Plan does
not have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve second opinion visit. You say that the enrollee's daughter has a friend who
is a neurosurgeon, and the enrollee wants a second opinion with this provider. The Plan denied your request.
The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with
the Plan and the enrollee can be treated within the Plan 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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve
the medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the osteogenesis stimulator provided on
January 29, 2020.
You asked the Plan to waive the coinsurance for the osteogenesis stimulator. You say that you were told the
bone stimulator would be covered and you were not told you would have a copayment. The Plan denied your
request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies.
You have been asked to pay $751.20 which is 20% of the allowed amount for the osteogenesis stimulator. The
allowed amount is $3,756.03. ($3,756.03 x 20% = $751.20). The osteogenesis stimulator falls within the
"Durable medical equipment (DME) and related 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 coinsurance for the osteogenesis stimulator provided on January 29, 2020.