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

We decided that the Plan does not have to pre-approve Synvisc One. 
 
You asked the Plan to pre-approve the Synvisc One. 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 Synvisc One. Our reviewer says that 
the member has not trialed the Plan's preferred viscosupplemental treatments Orthovisc and Monovisc. Our 
physician reviewer found the documentation does not outline contraindications or reasons these medications 
were not considered. 
 
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 Synvisc One have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Synvisc One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased December 4, 2018. 
 
You asked the Plan to pay for the hearing aids. You say that you should be covered for both being in or out of 
network and feel that under your guidelines you clearly meet the qualifications. The Plan denied your request. 
The Plan says hearing aids are not covered under the plan benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services. The plan contract on page 86 says that routine hearing exams, hearing aids or exams to fit hearing aids 
are not covered.  
 
Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pay for the hearing aids 
purchased December 4, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 19, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the office visit (99213) provided on November 19, 2019. You say that you would 
like reconsideration because you have been seeing this provider frequently. The Plan denied your request. The 
Plan says this provider is not in-network and these services are not urgent, emergent or authorized. 
 
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 November 19, 
2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for your routine transportation. 
 
You asked the Plan to pre-approve additional miles. The Plan denied your request. The Plan says your benefit 
only allows 50 miles. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case.  
 
The documentation shows that transportation over 50 miles was requested. We looked at your request, the 
records in the case file, and the rules. Your plan benefit only covers transportation for up to 50 miles per one-
way trip. Based on this information, we decided that the Plan?s rules for coverage of routine transportation have 
not been met. Therefore, we decided that the Plan does not have to pre-approve additional mileage for your 
routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic lab services provided by a 
participating provider on May 6, 2020. 
 
You asked the Plan to waive the copayment for diagnostic lab services. You say that you are being incorrectly 
charged. You say that you know it's only $5 but it is the principle. The Plan denied your request. The Plan says 
the correct copayment 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 $5 
copayment for outpatient diagnostic tests/lab services.  
 
You have been asked to pay a $5 copayment for diagnostic lab services. The correct copayment has been 
applied to the services that were provided. Diagnostic lab services falls within the outpatient diagnostic 
tests/lab 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 diagnostic lab 
services provided by a participating provider on May 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
March 17, 2020. 
 
You asked the Plan to pay for genetic testing. You say that this testing was deemed medically necessary by the 
enrollee's treating physician. The Plan denied your request. The Plan says the denial of payment for this testing 
is correct, because this testing was not billed with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that comprehensive genomic profile testing must be 
billed using code CPT 81479 for date of service March 17, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for revascularization services (37222) provided on October 28, 
2019. 
 
You asked the Plan to pay for the revascularization services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service billed. 
 
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 37222 is revascularization, endovascular, open or 
percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately 
in addition to code for primary procedure). 
 
We asked our coder 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 revascularization services. Our reviewer says that CPT 
code 97222 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative 
report documents left external iliac artery angioplasty, left common iliac artery angioplasty, right common iliac 
artery angioplasty and right external iliac artery angioplasty was performed. The operative report did not 
include CPT add on code, 37222. 
 
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 revascularization services have not been met. Therefore, we decided that the 
Plan does not have to pay for revascularization services (37222) provided on October 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you are not healthy enough to be dismissed to a skilled nursing facility (SNF) and may get sick from other people at a SNF. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met.
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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) following spinal surgery. The enrollee's post-operative course has been complicated by respiratory difficulty due to heavy secretions. The enrollee was intubated/ventilated several times and subsequently received a tracheotomy. The enrollee is tolerating tracheotomy trials. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Vincristine sulfate (J9370), Cytarabine (J9098), and Rituximab-
ABBS (Q5115). 
 
You asked the Plan to pre-approve the requested drug regimen. You say that the treatment provided is 
reasonable and medically necessary for the enrollee's diagnosis. The Plan denied your request. The Plan says 
that use of the drugs with the enrollee's specific chemotherapy regimen is not supported. 
 
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 requested drug regimen was ordered by a Par provider. The rules say that a contract plan provider is an 
agent of the plan. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information, including medical records, regarding their decision to deny your request.  Therefore, we decided 
that the Plan has to pre-approve Vincristine sulfate (J9370), Cytarabine (J9098), and Rituximab-ABBS 
(Q5115).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on March 8, 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 services were not urgent or emergent, nor were they approved in advance. 
 
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 rendering 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 lab services provided to the enrollee on March 8, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 20, 
2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 G0483 is not supported in the medical record. Specifically, the documentation 
submitted did not include a valid physician order/lab requisition form or medical records signed by the ordering 
physician stating exactly what tests were to be performed. Based on this information, we decided that Medicare 
rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the drug testing coded G0483 provided on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (97112, 97032, 97016, 96372, J3490, 
J3420, J3415 and J3411) provided on December 12, 2019. 
 
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says these services are not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services (97112, 97032, 97016, 96372, J3490, J3420, J3415 and 
J3411) provided on December 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 the enrollee does not require services at the proposed LTACH that are not already 
available at the current acute care facility. Therefore, this request for LTACH services will be considered not 
medically necessary. Transfer to home or a skilled nursing facility in the near future appears to be most 
appropriate. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the PILD procedure provided on January 17, 2020. 
 
You asked the Plan to pay for the procedure. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when 
provided in a clinical study.  
 
We looked at the file and Medicare rules. The records do not show that the services in question were provided 
as part of a clinical trial. Based on this information, we decided that Medicare rules for coverage of the 
procedure have not been met. Therefore, we decided that the Plan does not have to pay for the PILD procedure 
provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve the proton beam therapy. You say that the records provided support the need 
for proton beam therapy. The Plan denied your request. The Plan says proton beam therapy is not medically 
necessary. The Plan says that IMRT is the standard of care for prostate cancer. 
 
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 proton beam therapy. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the theoretical advantage of proton beam therapy is in its dose distribution. Proton 
beam therapy thus permits the delivery of high doses of radiation therapy to the target volume while limiting 
the "scatter" dose received by surrounding tissues.  Use of proton beam radiation therapy is expanding as more 
proton beam treatment centers open. However, there are no randomized trials comparing proton beam therapy 
with photon therapy or brachytherapy in men with clinically localized prostate cancer. A systematic review of 
the available evidence from ASTRO on efficacy and toxicity concluded that outcomes were similar with proton 
beam therapy and intensity-modulated radiation therapy (IMRT) using photons, but did not demonstrate a 
benefit for the proton beam approach.  Clinical practice guidelines have concluded that proton beam therapy 
offers no clinical advantage over other forms of definitive treatment. 
 
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 proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on July 13, 2018.
You asked the Plan to waive the copayment for a specialist office visit. You say that you would like someone to take care of this bill. The Plan denied your request. The Plan says the correct copayment 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 $30 copayment for physician/practitioner services/specialist visit. You have been asked to pay a $30 copayment for a specialist office visit. The correct copayment has been applied to the services that were provided. A specialist office visit falls within the physician/practitioner services/specialist visit 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 a specialist office visit provided by a participating provider on July 13, 2018.
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 are now mostly moderate/maximum assist 
for care. You have no complex wound care needs, or IV medication requirements. There are no nursing or 
therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care (including long term 
care placement). 
 
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 the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve surgical service. You say that you believe this procedure is medically 
necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the requested provider is out-of-network with the Plan and the enrollee can be treated by an in-network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.