Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.
You asked the Plan to pre-approve a grab bar. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because
they are not primarily medical in nature.
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on
December 2, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you should not owe
more than the specialist copayment. 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 20%
coinsurance for Medicare Part B prescription drugs.
You received a Medicare Part B drug on December 2, 2019. The allowed amount is $604.16 and 20% of that is
$120.83.
You have been asked to pay the total coinsurance amount of $120.83 for a Medicare Part B drug. A Medicare
Part B drug 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 Medicare Part B drug provided on December 2, 2019.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not 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 preapprove
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 do not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require
intensive physician and nursing oversight only in an IRF. The documentation does not support that the
enrollee's functional status or activity tolerance 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 for the
enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Rituxan (J9312).
You asked the Plan to pre-approve Rituxan. You say that this is medically necessary.
The Plan denied your request. The Plan says that this is not indicated for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
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 Rituxan. Our reviewer says that the use
of Rituxan is supported in this case. Our physician reviewer found this use of Rituxan is supported in numerous
CMS-approved medical journals. The submitted medical records show that Rituxan is safe, effective, and
otherwise reasonable and necessary for this 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 Rituxan have been met. Therefore, we decided that the Plan has to pre-approve
Rituxan (J9312).
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy provided on
January 30, 2020.
You asked the Plan to waive the copayment for the colonoscopy with biopsy. You say that there should be no
copayment for a preventive procedure. 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 $250
copayment for each Medicare-covered in-network outpatient hospital facility visit.
You have been asked to pay a $250 copayment for the colonoscopy with biopsy. The colonoscopy with biopsy
falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers" benefit category. The medical record shows a preoperative diagnosis of a history of
adenomatous colon polyps which makes the colonoscopy diagnostic in nature.
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 colonoscopy with biopsy provided on January 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyaluronan Injections (J7326).
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan
denied your request. The Plan says coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that Hyaluronan injections are covered when the patient
has failed at least three months of conservative therapy
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 injections. Our reviewer says that
the injections are not medically necessary. Our physician reviewer found the record does not substantiate that
the enrollee failed a three month trial of conservative 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 the injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve Hyaluronan Injections (J7326).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on January 21, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not supported.
The Plan must follow Medicare rules. Medicare rules say that Gurdant360 testing is covered when specific criteria are met. We looked at the file and Medicare rules. There is no submitted documentation to support that the criteria for
coverage are met. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the vision services rendered on March 10,
2020.
You asked the Plan to waive the coinsurance for these services. You say that you assumed most of the expenses
would be covered. The Plan denied your request. The Plan says the coinsurance was 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 45% of
the total cost for members eligible for out-of-network Medicare-covered vision care.
Review of the file shows that you received vision care services from an out-of-network provider. You have
been asked to pay 45% of the total cost for these services, for a total of $54.66. These services fall within the
out-of-network Medicare-covered vision 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. The Plan also applied a charge of $137.54 for these services. This charge is
the difference between the provider's fees and the Plan's fee schedule amount for these services. Given that the
provider is not a network provider with the Plan, the Plan cannot cover these charges.
Therefore, we decided that the Plan does not have to waive the coinsurance for the vision services rendered on
March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided on January 10, 2020.
You asked the Plan to pay for genetic tests. You say that neither the enrollee nor the ordering provider
physically attended your facility, and you do not have information about the enrollee's insurance requirements,
limitations, or conditions. The Plan denied your request. The Plan says the denial of payment for these services
is correct, because these tests are not covered by Medicare for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The tests at issue in this appeal, genetic tests, were requested solely for screening purposes. Medicare does not
cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for
genetic screening testing provided on January 10, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis.
Prior treatment has included three corticosteroid knee injections. He has not tried and failed the Plan's required
drugs of Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or
less effective; therefore, the Genvisc 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Genvisc.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections.
You asked the Plan to pre-approve Euflexxa. You say that the injections are medically necessary. The Plan
denied your request. The Plan says 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 Euflexxa. Our reviewer says that the
requested injections are not medically necessary. Our physician reviewer found there were no x-rays included
in the record to support the diagnosis. The provided records do not support that the injections are 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 24, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that this testing was medically necessary. The Plan
denied your request. The Plan says the denial of payment for this service is correct, because this provider is
out-of-network with the Plan and authorization was not obtained.
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 on October 24, 2019
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (D7311).
You asked the Plan to pre-approve alveoloplasty in conjunction with extractions. You say that the services are
necessary. The Plan denied your request. The Plan says the service is not a covered benefit.
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
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397)
provided to the enrollee on November 30, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with
suspension sleeve (L1851, L2397) provided to the enrollee on November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services for an
ophthalmological exam provided on April 28, 2020.
You asked the Plan to waive the copayment for the physician's services for an ophthalmological exam. The
Plan denied your request. The Plan says the exam is not considered routine and a $50 specialist copayment
applies.
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
copayment for vision care, Medicare-covered exams.
You have been asked to pay $50 copayment for the physician's services for an ophthalmological exam. The
physician's services for an ophthalmological exam falls within the Vision Care, Medicare-covered 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 physician's services for an ophthalmological
exam provided on April 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on February
25, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that the ambulance was
unnecessary because you could have had your daughter take you. 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 $250
copayment for ambulance services.
You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall 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 services
provided on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar sacral orthosis for the enrollee.
You asked the Plan to pre-approve a lumbar sacral orthosis. The Plan denied your request. The Plan says that
medical necessity criteria 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 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 a lumbar sacral orthosis. Our reviewer
says that the requested item is not considered medically reasonable and necessary in this case. The
documentation does not reveal physical exam findings that indicate that the patient's pain will be reduced by
restricting mobility of the trunk; that there has been a recent injury to the spine or soft tissues that requires
healing or that there has been a recent surgery to the spine and related soft tissue that requires healing. There is
no evidence on a physical exam of weak spinal muscles or a deformed spine. Our physician reviewer found that
the enrollee's condition does not meet Medicare criteria for a lumbar sacral orthosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a lumbar sacral orthosis have not been met. Therefore, we decided that the Plan
does not have to pre-approve a lumbar sacral orthosis for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met.
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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to
safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not have
complex wound care or other ongoing SNF level SN need. Her functional does not require skilled therapy
services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively
provide medically necessary and reasonable treatment in a SNF. She does not require skilled nursing or skilled
therapy services (or a combination of these services) on a "daily basis" in a SNF. Medicare coverage criteria for
SNF services are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on February 15, 2020 to
February 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient hospital services. You say that you would like this claim reprocessed
and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained.
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 outpatient hospital services provided on February
15, 2020 to February 18, 2020 by an out of network (OON) provider.