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

 
We decided that the Plan does not have to pre-approve RELISTOR 150mg tablets. 
 
You asked the Plan to pre-approve the RELISTOR tablets. You say that the enrollee has a history of colon 
cancer and Naloxegol was not helpful. The Plan denied your request. The Plan says this oral drug cannot be 
covered by Medicare Part B. 
 
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 pre-approve RELISTOR 150mg tablets.  
 
Benefits for the RELISTOR tablets 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the Medicare criteria for IRF. The 
Plan denied your request. The Plan says the denial of authorization for IRF service is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee does need physical and occupational therapy, the rehabilitation needs are not complex and do not 
require an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa (J7323). You say that you want to be treated with this drug. The 
Plan denied your request. The Plan says you have not first tried and had a contraindication or intolerance to 
Orthovisc and Monovisc. 
 
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 Euflexxa (J7323). Our reviewer says 
that the drug is not reasonable and medically necessary. Our physician reviewer found criteria is not met. There 
is no documentation of failure of intolerance to first line drug therapy with Orthovisc or Monovisc.  
 
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 (J7323) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the care is not complex enough and does not show it would cause 
excessive physical hardship for you to receive needed care on an outpatient basis or skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
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: 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 these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
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. You are 
currently undergoing treatment at an acute care hospital (ACH) for a large stroke complicated by herniation. 
You were intubated/ventilated and subsequently received a tracheotomy. You are noted to be unresponsive. 
There is no evidence that you require services that are not currently available. As LTACHs and ACHs are 
licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can 
remain at the current ACH until such time no acute services are required. You can then be 
transferred/discharged to a lower level of care for any ongoing long term care needs. Our physician reviewer 
found that your 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydroxyzine. 
 
You asked the Plan to pre-approve Hydroxyzine. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 pre-approve Hydroxyzine.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve the OON PT services. You say that you do not understand why this is 
denied when you have been receiving PT from this provider for the month of July. You believe that this is a 
network provider and that you should be able to continue receiving services here. The Plan denied your request. 
The Plan says you began with this provider without authorization and there are network providers nearby who 
can provide the PT you require. 
 
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 
physical therapy (PT) services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Durolane. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has pain related to osteoarthritis of both knees, the diagnosis has been confirmed 
with imaging studies. The enrollee has failed conservative treatment. The documentation does not support that 
the enrollee has tried and failed drugs Monovisc and Orthovisc. The documentation does not support any 
indication that the required drugs would likely be less effective and/or likely have adverse effects for the 
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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hysterectomy surgery. 
 
You asked the Plan to pre-approve hysterectomy. You say that you need this surgery. The Plan denied your 
request. The Plan says the denial of authorization for this service is correct, because there is no physician 
recommendation for this surgery, and it is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve hysterectomy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found women with uterine fibroids without symptoms generally do not need surgery. Your treating 
obstetrics/gynecology specialist does not indicate that you need this surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hysterectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hysterectomy surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
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 medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of stage III 
non-small cell lung cancer (NSCLC). The FDA label states the drug is indicated for the treatment of adult 
patients with unresectable Stage III non-small cell lung cancer (NSCLC) whose disease has not progressed 
following concurrent platinum-based chemotherapy and radiation therapy. He has been treated for over 12 
months, since May of 2019, with Imfinzi and the records do not support that the continuation of the drug is safe 
and effective 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 Imfinzi.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the facet joint injections. You say that you would like reconsideration 
because this service is medically necessary and effective. The Plan denied your request. The Plan says there is 
insufficient information to determine that non-facet pathology has been considered or ruled out. 
 
The Plan follows Medicare rules. Medicare rules say that this service is indicated when enrollees meet specific 
criteria. 
 
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 facet joint injections. Our reviewer 
says that This procedure is not medically reasonable and necessary. Our physician reviewer found The LCD 
states that enrollees must meet specific criteria in order for this service to be indicated. The provided medical 
records do not document that you have satisfied all of these requirements. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services provided to the enrollee on 
March 8, 2019. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of a covered diagnosis for the requested testing. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found no provider records have been submitted for review. Therefore, there is no evidence to support that the 
provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's 
condition(s). 
 
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 molecular pathology services provided to the enrollee on March 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 11, 
2020 through January 24, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your 
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim 
was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you were admitted on January 11, 2020 and discharged on January 24, 2020. You 
were asked to pay a $195 copayment per day from January 11, 2020 through January 17, 2020, days 1-7 of 
your inpatient stay. There were no copayment charges from January 18, 2020, day 8 of your inpatient hospital 
care until your day of discharge January 24, 2020. Per your contract there is a $195 copayment per day required 
for days 1-7. 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 inpatient hospital care from January 11, 
2020 through January 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray (73565) provided on January 24, 2020. 
 
You asked the Plan to pay for the knee x-ray. 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 73565 is radiologic examination, knee; both knees, 
standing, anteroposterior. 
 
 
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 knee x-ray. Our reviewer says that CPT code 73565 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not 
include a radiological report with interpretation to support service billed. 
 
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 knee x-ray have not been met. Therefore, we decided that the Plan does not 
have to pay for the knee x-ray (73565) provided on January 24, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the deductible for the laboratory services rendered on April 22, 2020 to 
May 4, 2020. 
 
You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says that the deductible was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 copayment for Medicare-covered laboratory tests.  
 
The Plan says you must pay a $27.05 deductible per date of service for these services, for a total of $54.10. 
Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for these services. 
The Plan contract does not list that there is a $250 yearly deductible that must be met prior to having a $0 
copayment for these services. Therefore, we decided that the Plan has to waive the deductible for the laboratory 
services rendered on April 22, 2020 to May 4, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit (99214) provided 
on April 27, 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 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 clearly says that you must pay a $40 
copayment for a specialist office visit.  
 
You have been asked to pay a $40 copayment for the specialist office visit provided via telehealth services. 
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 specialist office visit (99214) provided on April 27, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI, spinal canal and contents, lumbar; 
without contrast material provided to the enrollee on April 11, 2019. 
 
You asked the Plan to waive the copayment for the MRI. You say that you are appealing the member's cost-
share responsibility for the services the member received. The Plan denied your request. The Plan says the 
claim was processed accordingly with the member's 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
There is a $50.00 copayment for each complex procedure, test, and radiology except PET scans.  Review of 
medical records provided show that the enrollee had an MRI twice on the one day.  These are two separate 
procedures and per the enrollee's EOC 2019, there is a $50.00 copayment for each Radiological Diagnostic 
service. 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 MRI, spinal canal and 
contents, lumbar; without contrast material provided to the enrollee on April 11, 2019.