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

 
We decided that the Plan does not have to pay for the established patient assisted living visit with brief 
emotional or behavioral assessment (99336, 96127) provided on June 23, 2020, by an out of network (OON) 
provider. 
 
You asked the Plan to pay for the established patient assisted living visit with brief emotional or behavioral 
assessment. You say that the service provided was medically necessary. The Plan denied your request. The 
Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been 
correctly denied. 
 
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 established patient assisted living visit with 
brief emotional or behavioral assessment (99336, 96127) provided on June 23, 2020, by an out of network 
(OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869) and insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (List separately in addition to code for primary procedure) (CPT Code 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer is experimental. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CPT Code 22869 and CPT Code 22870.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found transfer to a LTACH is not medically necessary at this time. The enrollee is receiving 
appropriate care at the current acute care facility. The review has determined that the enrollee does not require 
services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 LTACH 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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. 
 
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. 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 
was admitted for a lumbar laminectomy. The enrollee's medical problems are stable and there are no identified 
problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost shares for the IV therapy services you received from 
January 9, 2020, to January 23, 2020. 
 
You asked the Plan to waive the cost shares for the services provided. You say that your obligation should be 
$140 per year. The Plan denied your request.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs, and a $10 copay for lab 
services. The services fall within the Medicare Part B prescription drugs and outpatient diagnostic tests benefit 
categories. 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 cost shares for the IV therapy services you received from 
January 9, 2020, to January 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Prolia injection (J0897) received on May 
18, 2020. 
 
You asked the Plan to waive the coinsurance for a Prolia injection. You say that the amount charged is not 
consistent with previous coinsurance. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 Part B drugs that are administered by a provider.  
 
You have been asked to pay $237.64 coinsurance, or 20% of the Plan-allowed amount of $1,188.18, for a 
Prolia injection. A Prolia injection falls within the "Medicare Part B prescription drugs" 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 a Prolia injection (J0897) received on May 18, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab injection (CPT Code J9312).
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied
your request. The Plan says this requirement encourages the enrollee to try the Plan's preferred drug(s), which
is/are just as effective: Inflectra or Remicade, AND Simponi Aria.

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 the provided records state that the patient has not tried and failed Remicade or Inflectra and Simponi
Aria. The preferred Remicade or Inflectra and Simponi Aria would not be any less effective or have more
adverse effects compared to the requested Rituxan. Current literature shows that each of the available
infliximab biosimilars including rituximab have essentially equal effectiveness and safety in this clinical
situation.

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 Rituximab injection (CPT Code J9312).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic parenteral drug (D9610) provided on July 7, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you have anxiety and a severe gag reflex. You 
say that your tooth was jagged and protruding in your jaw. You also say that the tooth has long roots. The Plan 
denied your request. The Plan says therapeutic parenteral drug is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
therapeutic parenteral drug (D9610) provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection, triamcinolone acetonid (J3301) and injection, 
intralesional (11900) provided on July 23, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for injections. You say that the services were medically necessary. The Plan denied 
your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-
of-network provider. There are multiple in-network providers available to provide these services in your area. 
 
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 injection, triamcinolone acetonid (J3301) and 
injection, intralesional (11900) provided on July 23, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a TENS unit (E0730). 
 
You asked the Plan to pre-approve the TENS unit. You say that you would like reconsideration because the 
Plan has approved this equipment in the past and you need a replacement. The Plan denied your request. The 
Plan says the records do not show that you are enrolled in an approved clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS therapy for CLBP is covered when you 
are enrolled in an approved clinical study 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS unit have not been met. Specifically, the records do not show that you are enrolled in an 
approved clinical study. Therefore, we decided that the Plan does not have to pre-approve a TENS unit 
(E0730).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva 120 MG/1.7 ML Vial 1.7/28 
 
You asked the Plan to pre-approve Xgeva. 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 Xgeva. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has bone metastases from small cell lung cancer. The enrollee has not received 
prior therapy for the bone involvement. Neither pamidronate nor zoledronic acid have been tried. There is no 
indication on why either of these drugs would be unsuitable. Therefore, the enrollee does not meet criteria for 
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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva 120 MG/1.7 ML Vial 1.7/28
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on October 27, 2018 by 
an out-of-network provider. 
 
You asked the Plan to pay for emergency room services. You say that you submitted the claim in time. The 
Plan denied your request. The Plan says non par providers have 365 days from the date of service to submit a 
claim for payment. 
 
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 emergency room services was not filed until October 27, 2020. 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 emergency room services provided on October 27, 2018 by an 
out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
on August 14, 2020. 
 
You asked the Plan to pay for the dental service. You say that you went in for a routine cleaning. You say that 
you paid a $25 copayment. You also say that you received a letter saying the fluoride varnish application was 
denied. The Plan denied your request. The Plan says fluoride varnish application is not listed as a covered 
service. The Plan also says procedures not shown in the Addendum are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
topical application of fluoride varnish (D1206) provided on August 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for out-of-network physician services (99222) 
provided in an inpatient hospital on April 27, 2020. 
 
You asked the Plan to waive the coinsurance for out-of-network physician services. You say that you were not 
given a choice as to the out-of-network provider. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 30% 
coinsurance for provider and professional services at an inpatient hospital.  
 
You have been asked to pay $40.49, or 30% of the Plan-allowed amount of $134.98, for out-of-network 
physician services. Out-of-network physician services fall 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 coinsurance for out-of-network physician services (99222) provided in an 
inpatient hospital on April 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for allergen immunotherapy provided on 
January 17, 2020, and January 28, 2020. 
 
You asked the Plan to waive the copayments for allergen immunotherapy. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct 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 $20 
copayment per visit to a specialist. 
 
You received allergen immunotherapy on January 17, 2020. Therefore, you are responsible to pay the allowed 
amount of $10.36.   
 
You received allergen immunotherapy on January 28, 2020. Therefore, you are responsible to pay the allowed 
amount of $10.36.   
 
The total amount you owe is: $20.72.  
 
You have been asked to pay the total copayment amount of $20.72 for allergen immunotherapy. Allergen 
immunotherapy falls within the physician/practitioner services, including doctor's office visits 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 copayments for allergen immunotherapy provided on January 17, 2020, and 
January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit (99337) provided on June 5, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary visit. You say that medically necessary services were rendered in 
good faith. The Plan denied your request. The Plan says this provider is not a network provider, nor was the 
service urgent or emergent. 
 
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 domiciliary visit (99337) provided on June 5, 
2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
in the home health or hospice setting, each 15 minutes (CPT Code G0299). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our physician reviewer 
found the documentation does not support that skilled nursing services are required for the enrollee in this case. 
The records show that skilled therapy services are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to 
maintain the patient's level of function and/or prevent deterioration. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve direct skilled nursing services of a registered nurse (RN) in the home health or hospice 
setting, each 15 minutes (CPT Code G0299).