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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing and/or 
skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a 
lower level of care. Although further rehab services would be appropriate to improve function and strength, as 
a practical matter, the daily skilled services can be provided at a lower level of care than a skilled nursing 
facility. Admission to a SNF for inpatient skilled rehab services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis (27280). 
 
You asked the Plan to pre-approve arthrodesis. 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 arthrodesis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical records show that the enrollee has post laminectomy back pain. There is no 
documentation of spinal instability. There is no fracture or lesion. Criteria for spinal fusion not met. Spinal 
fusion is not indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis (27280).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 6, 
2019. 
 
You asked the Plan to pay for the domiciliary, rest home visit. You say that the enrollee was enrolled in 
Hospice from September 3, 2019 to November 1, 2019 and not in Hospice on November 6, 2019. The Plan 
denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 
prior authorization. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 1, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for a domiciliary, rest 
home visit provided on November 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the ambulance transportation services provided 
on April 8, 2020. 
 
You asked the Plan to waive the copay for the transportation services. You say that the emergency room would 
not take you if someone else drove you. The Plan denied your request. The Plan says the copay is a contractual 
obligation that cannot be waived. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copay for each Medicare-covered one-way trip by ground transportation.  
 
You have been asked to pay a $225 copay for the transportation services. The 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 copay for the ambulance 
transportation services provided on April 8, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 76775 provided on March 5, 2020. 
 
You asked the Plan to pay for CPT code 76775. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, CPT code 76775 was not billed with an appropriate 
modifier. This code must be submitted with a modifier of 26 to indicate "professional component" in a Part A 
stay. Therefore, we decided that the Plan does not have to pay for CPT code 76775 provided on March 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance transport (A0425, A0427) provided March 8, 
2020. 
 
You asked the Plan to pay for the ambulance transport. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim was submitted with an invalid modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A0425, A0427 is not supported in the medical record. Specifically, the claim uses the 
modifier "ET" to denote the origin and destination of the transport. "ET" is not a valid ambulance transport 
modifier. Based on this information, we decided that Medicare rules for coverage of the ambulance transport 
have not been met. Therefore, we decided that the Plan does not have to pay for an ambulance transport 
(A0425, A0427) provided March 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99190) provided on March 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this 
service is included in the Part A DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on March 9, 
2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for dental services provided on May 4, 2020 and May 12, 2020. 
 
You asked the Plan to pay for dental services. You say that your original dentist was unable to see you 
immediately. You say that you sent receipts for possible reimbursement. The Plan denied your request. The 
Plan says that the provider has been sanctioned and claims are not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not submitted documentation from a verified source showing this 
provider is sanctioned. Without evidence of sanctions from a verified source, the denial of payment is not 
substantiated. Therefore, we decided that the Plan has to pay for dental services provided on May 4, 2020 and 
May 12, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oncology (thyroid) gene expression 
analysis, a genetic test, on April 22, 2020. 
 
You asked the Plan to waive the coinsurance for the genetic test. You say that you didn't request this genetic 
testing, so you shouldn't have to pay for it. The Plan denied your request. The Plan says you were charged this 
coinsurance 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 20% 
coinsurance for genetic testing.  
 
You have been asked to pay 20% coinsurance for the genetic test. Records show that you had this testing. 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, regardless of who 
requested the testing. Therefore, we decided that the Plan does not have to waive the coinsurance for the 
oncology (thyroid) gene expression analysis, a genetic test, on April 22, 2020.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for injections. We decided that the Plan does not have 
to waive the coinsurance for injections.  
 
You asked the Plan to waive the coinsurance for injections. You say that you already met your out-of-pocket 
maximum. The Plan says that the correct coinsurance has been 
 
We decided that the Plan has to waive the coinsurance for injections.  
 
There is a 20% coinsurance for injections. You are being asked to pay 20% of the allowed amount for 
injections. The total allowed amount is $4,891.20. The total amount you are being asked to pay is $978.24 
($4,891.20 x 20% = $978.24). Therefore, we decided that the Plan has to reduce the coinsurance for injections.  
 
We also decided that the Plan does not have to waive the coinsurance for injections. 
 
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% 
coinsurance for injections. Therefore, we decided that the Plan does not have to waive the coinsurance for 
injections. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99203) received on April 1, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
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 services was not filed until April 14, 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 the services (CPT 99203) received on April 1, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the 
enrollee on March 19, 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 the documentation submitted indicate that definitive, utilizing drug identification methods results 
with less than 22 drug classes were performed; therefore, the billed service cannot be verified. 
 
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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) 
drug identification methods able to identify individual drugs and distinguish between structural isomers (but 
not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS 
(any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic 
methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in 
all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method 
or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument 
variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, 
per day; 22 or more drug class(es), including metabolite(s) if performed." 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
documentation submitted indicate that definitive, utilizing drug identification methods results with less than 22 
drug classes were performed; therefore, the billed service cannot be verified. In addition, there is a more 
appropriate Healthcare Common Procedure Coding System (HCPCS) code (G0480) that should be used to bill 
for service performed. The review has determined that the records do not support that G0483 was performed. 
The code could not be verified. 
 
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 pay for drug testing services (HCPCS G0483) provided to the enrollee on March 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy visits. 
 
You asked the Plan to pre-approve 6 additional physical therapy visits. You say that you are appealing to 
receive the 6 remaining visits. The Plan denied your request. The Plan says additional visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 6 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee has had extensive therapy and was 
instructed in a home exercise program. Our reviewer says that the enrollee is at a functional level that does not 
require ongoing skilled 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 6 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
requested service is not covered for your condition. 
 
The Plan follows Medicare rules. Medicare rules say that stereotactic body radiation therapy is only covered 
under certain medical indications. 
 
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 requested services. Our physician 
reviewer found that you have a history of severe cardiac myopathy, refractory ventricular tachycardia with 
multiple episodes of recent ICD shocks (from an automated implantable converter defibrillator), persistent 
palpitations and clinical decline from heart failure. You have been refractory to medical management. Cardiac 
ablation was not considered feasible. A review of the records does not show that the coverage criteria have 
been met. Therefore, the requested services are not considered 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve stereotactic body radiation therapy.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
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 looked at the file and Medicare rules. The file does not contain any documentation or medical records to 
support that the Prolia is required for the enrollee. The Plan made a reasonable effort to obtain medical records 
for this enrollee but a response was not received. 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 
Prolia.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Rituxan. 
 
You asked the Plan to pre-approve the Rituxan. You say that you would like reconsideration because this 
therapy is medically necessary. The Plan denied your request. The Plan says that the indication requested does 
not meet criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Rituxan. Our reviewer says that 
fibrillary glomerulonephritis is a fairly uncommon condition with limited treatment options.  There is some 
evidence that Rituxan may be beneficial. Our physician reviewer found due to the limited treatment options and 
the consequences of this condition, this therapy is indicated and reasonable. 
 
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 Rituxan have been met. Therefore, we decided that the Plan has to pre-
approve Rituxan.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hypoglossal nerve stimulation to treat obstructive sleep 
apnea. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
records do not show a medical reason the device is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that hypoglossal nerve stimulation for obstructive 
sleep apnea is only covered under certain medical indications.  
 
We looked at the file and Medicare rules. Based on the information in the provided medical records, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pre-approve hypoglossal nerve stimulation to treat obstructive sleep apnea.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve the Hyalgan. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception criteria. 
 
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 Hyalgan. Our reviewer says that 
there is no documentation that the enrollee has been treated previously with Monovisc or Orthovisc, or that 
these preferred plan alternatives would not be medically appropriate for this enrollee. Our physician reviewer 
found there is insufficient documentation that step therapy or step therapy exception criteria have been 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 the Hyalgan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyalgan.