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

 
We decided that the Plan does not have to pay for the CT of the thorax provided on May 18, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the CT of the thorax. You say that no authorization is required. The Plan denied 
your request. The Plan says the service was rendered by a non-network provider who does not work with the 
enrollee's health plan. The Plan also says that the enrollee was referred by a non-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 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 CT of the thorax provided on May 18, 2020 by 
an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee cannot be care for at home in her 
condition. The Plan denied your request. The Plan says the enrollee has no daily skilled nursing or therapy 
needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and was 
treated for a urinary tract infection. There are no identifiable skilled nursing service needs. Regarding rehab 
services, the enrollee is at a contact guard assist level with functional mobility. She required varying assist with 
activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not 
require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a SNF setting. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira. 
 
You asked the Plan to pre-approve Humira. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says Humira is not covered under the enrollee's Medicare Part B 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 Humira.  
 
Benefits for Humira 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve reduction mammoplasty surgery. 
 
You asked the Plan to pre-approve reduction mammoplasty. You say that you have experienced decrease in 
breast volume on the left side and need reduction of the right side for symmetry. The Plan denied your request. 
The Plan says that the denial of authorization for this service is correct, because imaging shows your breast 
implant is intact and therefore this request appears to be cosmetic. 
 
The Plan follows Medicare rules. Medicare rules say that reduction mammoplasty may be covered to reduce 
the size of hypertrophic breasts, reduce or alleviate symptoms caused by breast hypertrophy, or reduce the size 
of a normal breast to bring it into symmetry with a breast reconstructed after breast cancer surgery. 
 
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 reduction mammoplasty. Our reviewer 
says that you meet the Medicare criteria for the requested reduction mammoplasty surgery. Our physician 
reviewer found the plan for you is consistent with typical breast reconstruction for deformities as the result of 
medically necessary treatment of breast cancer. Therefore, attempts to correct volume asymmetry in this case 
are consistent with reconstructive surgery to approximate a more normal appearance in the breast. Therefore, 
this procedure satisfies medically necessary criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of reduction mammoplasty have been met. Therefore, we decided that the Plan has 
to pre-approve reduction mammoplasty surgery.  
 
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 pay for the services rendered on August 22, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
 
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the services rendered on 
August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99215) to be provided by an out of 
network provider. 
 
You asked the Plan to pre-approve the office visit. You say that you would like to continue using this provider. 
The Plan denied your request. The Plan says there are network providers available that can provide this service. 
A single transition visit has been approved. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Please note the plan has approve one transition visit. Therefore, we decided 
that the Plan does not have to pre-approve an office visit (99215) to be provided by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX. 
 
You asked the Plan to pre-approve Supartz FX. The Plan denied your request. The Plan says the enrollee has 
not met the step therapy requirements. 
 
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 Supartz FX. Our reviewer says that the 
enrollee has not met the step therapy requirements for coverage of the requested drug. Our physician reviewer 
found that based on the medical records provided, the enrollee has not tried and failed the Orthovisc and 
Monovisc. There is no indication that the Plan's 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 Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure. 
 
You asked the Plan to pre-approve a Vertiflex procedure. The Plan denied your request. The Plan says this 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 a Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this device is experimental. More research is needed to show safety and efficacy 
of this device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on July 2, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were told you to go 
the emergency room by an in-network provider. 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 $120 
copayment for emergency care.  
 
You have been asked to pay a $120 copayment for an emergency room visit. Since an emergency room visit 
was provided, the correct copayment has been applied. An emergency room visit falls within the emergency 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit 
provided by a participating provider on July 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 16, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you didn't request the 
ambulance service, the hospital did.  You say that you shouldn't have to pay this copayment because you didn't 
ask to be transported. The Plan denied your request. The Plan says you were charged this copayment 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 $225 
copayment for ground ambulance services.  
 
You have been asked to pay a $225 copayment for the ambulance services. This copayment applies regardless 
of the reason for the ambulance transport. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance 
services provided on May 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from March 3, 
2020 to March 25, 2020. 
 
You asked the Plan to pay for services provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says that the Pricer re coded HIPPS code will be used for payment and 
will continue to be recorded in the APC-HIPPS field. This code will match the code on the electronic 
remittance advice. HHAs will be able to recognize this case because there will be three HIPPS codes on the 
claim record in DDE. In this case, the claim submitted has errors regarding these required codes.  
 
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 claim submitted cannot be paid 
due to coding errors.  Medicare rules for coverage of this service have not been met. Therefore, we decided that 
the Plan does not have to pay for home health services provided to the enrollee from March 3, 2020 to March 
25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRFadmission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee meets acute inpatient rehabilitation admission criteria under CMS guidelines. The Plan denied your request. The Plan says based on Medicare guidelines the enrollee does not meet the requirements.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 that based on review of the medical records, the enrollee is generally medically stable after a fall and spinal fractures in a TLSO. He does not meet the CMS coverage criteria for an IRF admission based on lack of medical and nursing needs and current functional status. There is no evidence of medical issues that require monitoring by an inpatient rehab physician three times a week. The documentation does not support that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care. This enrollee, does not meet the CMS coverage criteria for an IRF admission. His rehab needs can be met in an alternate, less intense setting such as in an SNF.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 IRFadmission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from February 5, 
2020, to February 14, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were transferred to 
another facility due to the hospital not being able to treat your condition. The Plan denied your request. The 
Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from February 5, 2020, to February 14, 2020. Therefore, you are responsible 
to pay a $300 copayment for days 1-5 (February 5, 2020, to February 9, 2020). $300 (copayment) x 5 (inpatient 
days) = $1,500.  
 
You have been asked to pay the total copayment amount of $1,500 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an inpatient hospital stay from February 5, 2020, to February 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-one (J7325). 
 
You asked the Plan to pre-approve Synvisc-one. The Plan denied your request. The Plan says the 
documentation does not meet Medicare criteria for approval. 
 
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 Synvisc-one. Our reviewer says that 
[state physician reviewer's conclusion, e.g. "the service is not medically necessary." or "you need this medical 
item."] Our physician reviewer found there is no documentation of an adequate trial of conservative measures 
to include physical therapy. Our reviewer also found that recent literature shows Synvisc is not effective for the 
management of knee degenerative joint disease pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-one have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-one (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foran out-of-network provider office visit on March 25, 2020.You asked the Plan to waive the coinsurance foran out-of-network provider office visit. You say that the claim was under-allowed.The Plan denied your request. The Plan says the correct coinsurance was 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). The enrollee's contract with the Plan clearly says that enrollees must pay 50% coinsurance for out-of-network provider and professional services. The enrollee has been asked to pay $36.03, or 50% coinsurance of the Plan-allowed amount of $72.06, for an out-of-network provider office visit. An out-of-network provider office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. 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 topay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance foran out-of-network provider office visit on March 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hearing services provided on May 13, 
2020. 
 
You asked the Plan to waive the copayment for hearing services. You say that you have never had to pay in the 
past. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for hearing services.  
 
You have been asked to pay a $20 copayment for hearing services. Hearing services fall within the hearing 
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 hearing services provided 
on May 13, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee will benefit from subacute rehab 
that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the enrollee 
does not require skilled services on a daily basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and his 
lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee 
was at a moderate to maximal assist level with functional mobility. He requires varying assist with activities of 
daily living. There are no identifiable skilled therapy service needs. He does not require skilled nursing or 
therapy services on a daily basis. He does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF setting. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.