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

We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided in an outpatient setting from March 7, 2021, to March 9, 2021.
You asked the Plan to pay for the self-administered drugs. You say that these services should be covered. The Plan denied your request. The Plan says self-administered drugs are not covered by Part B Medicare.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 pay for the self-administered drugs (A9270) provided in an outpatient setting from March 7, 2021, to March 9, 2021.
Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biologic materials to aid in tissue regeneration with periradicular surgery (D3431) for tooth # 27.
You asked the Plan to pre-approve the dental service. You say that you need this service. The Plan denied your request. The Plan says biologic materials to aid in tissue regeneration with periradicular surgery is not listed as a covered service. The Plan also says that the requested service is planned to be used in conjunction with a root canal and not periradacular surgery or apicoectomy.
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 pre-approve biologic materials to aid in tissue regeneration with periradicular surgery (D3431) for tooth # 27.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for the collection of a blood specimen from a completely implantable venous access device (36591) provided on January 22, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly to the service provided.
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 does not say in clear and accurate terms how much you should expect to pay for the collection of a blood specimen from an implantable venous access device. We looked at the file and your contract with the Plan. Based on this information, we find that you did not have a reasonable expectation that the blood draw through your implanted venous access device would be considered a surgical procedure. While this service may be coded as surgical, the performance of the service would not include many of the components that would reasonably be considered surgery by a layperson. There is no other benefit category in the EOC under which this service would be included other than lab testing. Because of this ambiguity, we find that you cannot be asked to pay more than a $0 copayment for the service at issue. Therefore, we decided that the Plan has to waive the copayment for the collection of a blood specimen from a completely implantable venous access device (36591) provided on January 22, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injection.
You asked the Plan to pre-approve Prolia Injection, denosumab, 1 mg (J0897). You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says the enrollee has not tried and failed zoledronic acid.
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 Prolia Injection, denosumab, 1 mg (J0897). Our reviewer says that the drug is not medically reasonable or necessary. Our physician reviewer found the patient has not tried and failed the required drug. There is no documentation provided indicating that Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. In addition, the enrollee does not have a history of an osteoporotic fracture. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia Injection, denosumab, 1 mg (J0897) have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation hospital stay
provided February 3, 2021, to February 5, 2021.
You asked the Plan to waive the copayment for the inpatient rehabilitation hospital stay. You say that the
enrollee should not be charged a second copayment because her entire hospital stay was at the same facility.
The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $250 copayment per day for days 1-3 of for each inpatient hospital stay.
It's considered a new admission if the enrollee is transferred from a hospital to a different type of facility such
as Acute Inpatient Rehabilitation.
The enrollee has been asked to pay a total of $500 ($250 copayment x 2 days = $500) for the inpatient
rehabilitation hospital stay. This hospital stay falls within the Inpatient Hospital Care benefit category. Though
the rehabilitation care may have been provided in the same building as the initial inpatient hospital stay, the
enrollee was discharged to a different level of care and admitted to a different type of facility. This means that
the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for the inpatient rehabilitation hospital stay provided February 3, 2021,
to February 5, 2021.
Your complaint about the policy to charge a second copay for inpatient hospital care at a different type of
facility and concerns about the language used in the EOC is not a valid appeal for medical coverage. This part
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
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 is a high risk for falls and injury. The Plan denied your request. The Plan says there is no need for an intensive rehabilitation therapy program.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute care hospital for altered mental status and a urinary tract infection. His medical problems are stable. There are no complex nursing needs. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a device evaluation to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an OON device evaluation. You say that you need to determine if you need 
a new pacemaker. The Plan denied your request. The Plan says this is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The 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 
a device evaluation to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 1 ST visit in the enrollee's home. 
 
You asked the Plan to pre-approve the ST visit. The Plan denied your request. The Plan says the conditions 
needed to approve the ST visit have not been met. 
 
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 ST visit. Our reviewer says that the 
requested home health ST services are not medically necessary or reasonable. Our physician reviewer found 
there is no valid physician order for the ST services. Our reviewer found that the diagnosis of systolic heart 
failure (I50.21) does not justify the ST services. Our physician reviewer also found that the ST evaluation does 
not show a need for skilled ST services. 
 
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 ST visit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 1 ST visit in the enrollee's home.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on December 15, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with this 
coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been 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 a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $1,235.28. The total amount you are being asked to pay is $247.06 ($1,235.28 x 20% = $247.06). An 
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 an injection provided by a participating provider on December 15, 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 you need to regain maximum function. The Plan 
denied your request. The Plan says you cannot tolerate an intensive therapy program. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that you were admitted to the acute care hospital for respiratory failure sepsis and pneumonia. Your medical 
problems are stable. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. The complexity of your nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97530) provided to the enrollee on 
May 12, 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 there is a more appropriate code to use in this case. 
 
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 97530 is "Therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes."

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 supported by the medical records. Our coding reviewer found the services 
were performed by a Certified Occupational Therapy Assistant (COTA) in the home; therefore, a Healthcare 
Common Procedure Terminology (HCPCS) code should be used to report these services. 
 
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 physical therapy services (97530) provided to the enrollee on May 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that your records show you no longer have an illness that requires 
you to be seen by a doctor every day and you do not need specialized nursing care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve the RFA services.. You say that you are in pain and take pain killers four 
times a day. The Plan denied your request. The Plan says that medical studies do not show that more injections 
would work. 
 
The Plan follows Medicare rules. Medicare rules say that repeat RFA services are covered when medically 
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 the RFA services.. Our reviewer says 
that the criteria for coverage have been met. Our physician reviewer found the enrollee has chronic cervical 
facet syndrome. She takes Oxycontin, Flexeril, Ibuprofen and Pamelor for pain. She has had both Left and 
Right RFA of the cervical medial branch blocks (MBBs) several times. Each time, the pain relief has been 
described as excellent (not quantified) but the neck pain isn't discussed again for greater than 6 months. The 
request is to repeat the RFA on the Left. Our physician reviewer found that the enrollee meets the requirement 
for the requested RFA services, which are medically reasonable and 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 RFA services. have been met. Therefore, we decided that the Plan has to 
pre-approve radiofrequency ablation (RFA) services.  
 
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 additional power wheelchair accessories (E2311, 
E2313, E2377) for the enrollee.

You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee's upper limb strength and function are adequate for the 
enrollee to be able to control the power options using their own switches which are included in the allowance 
of these power options. 
 
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 additional accessories. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records indicate the enrollee's right upper extremity strength is 4- to 4/5 
and that he is able to complete finger opposition with all digits of his right hand, thus indicating that his 
strength and function are adequate to control the power options using their own switches. 
 
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 additional accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the 
enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation 
(A0427) provided on March 21, 2021. 
 
You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you should 
not have to pay for this service. The Plan denied your request. The Plan says the copayment 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 a $175 
copayment for ambulance services.  
 
You have been asked to pay a $175 copayment for emergency ambulance transportation. The service at issue  
falls within the ambulance services benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
emergency ambulance transportation (A0427) provided on March 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Sara Plus sit to stand lift, patient lift, hydraulic or 
mechanical, includes any seat, sling, strap(s) or pad(s) (E0630). 
 
You asked the Plan to pre-approve a Sara Plus sit to stand lift. You say that the enrollee has tried numerous 
types of lifts and has found that the Sarah plus lift does not cause pain and is easier than all the others. The Plan 
denied your request. The Plan says the enrollee already has a functioning hydraulic lift and a sit to stand lift and 
there is no evidence that it is necessary for an additional electric sit to stand lift. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee,  it is not considered 
reasonable and necessary. 
 
The file shows that you have a hydraulic drive medical lift and a sit to stand lift. The hydraulic drive medical 
lift and the sit to stand lift serves the same purpose as a Sara Plus sit to stand lift. Therefore, we decided that the 
Plan does not have to pre-approve a Sara Plus sit to stand lift, patient lift, hydraulic or mechanical, includes any 
seat, sling, strap(s) or pad(s) (E0630).