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

We decided that the Plan does not have to pay for code R0070 Transportation of portable x-ray equipment and 
personnel to home or nursing home, billed to the enrollee for date of service November 22, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code R0070 (1 unit) remains 
not supported. The documentation submitted does not support an additional unit of the billed code R0070 as 
one unit has already been paid; therefore, the additional billed service cannot be verified. It is noted that 
multiple attempts were made to contact the provider for additional information. 
 
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 a previously billed service. The Plan states a corrected claim or additional information to explain the 
claim would be reviewed.  Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for code R0070 billed to the enrollee for date of service November 
22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for the physician visit provided on 
March 13, 2020. 
 
You asked the Plan to waive this cost share. You say that this office visit was always covered at no charge 
before. The Plan denied your request. The Plan says per the office notes dated March 13, 2020 this visit was an 
annual gynecology visit. Per the office notes dated March 2, 2020 this visit was an annual primary care visit 
with fasting labs. The visit on March 2, 2020 was charged by your primary care physician as your annual 
wellness visit.  The Plan states that enrollees are responsible for consulting the Plan contract for benefit 
information and/or contacting the Plan for questions. Per review of the call history, there is no indication you 
contacted the Plan prior to either appointment to verify coverage. Each claim was processed based on the 
information submitted by your physicians.   
 
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 one annual wellness 
for is only covered once per year. In addition, lab services and general diagnostic services are not part of the 
wellness visit. Any lab services or diagnostics resulting from any physician visit are charged separately.  
 
Therefore, we decided that the Plan does not have to waive the cost share charged for the physician visit 
provided on March 13, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital stay provided. 
 
You asked the Plan to pay for the inpatient hospital stay. You say that the inpatient level of care was medically 
necessary. The Plan denied your request. The Plan says that there was no evidence member?s treatment could 
not have been met at a less restrictive, outpatient level of care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
 
 
 
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 inpatient hospital stay. Our reviewer says 
that the inpatient level of care was medically necessary. Our physician reviewer found the treating physician 
documented, that the enrollee was not stable for transfer to a lower level of care. 
Furthermore, based upon a review of the records provided the admission of this patient does meet criteria for 
acute inpatient mental health treatment as she was shown to be a danger to herself but not others along with 
command auditory but no visual hallucinations. This enrollee did appear to require inpatient mental health 
treatment as she was a danger to herself but not others along with command auditory hallucinations. It did 
appear that active treatment was taking place. In addition, the services were reasonably expected to improve the 
patient?s condition or for the purpose of diagnosis. 
 
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 inpatient hospital stay have been met. Therefore, we decided that the Plan 
has to pay for the inpatient hospital stay provided.  
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for additional reimbursement for PPE and decontamination for 
ambulance services provided to the enrollee on April 7, 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 Medicare attests payment in full for all services, supplies, and other costs once the transport 
claim has been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of HCPCS code A0999 is "unlisted ambulance service." 
 
We find that CPT code A0999 is not supported in the medical record. Specifically, the payment for this code is 
included in the payment for the main ambulance service. 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 additional reimbursement for PPE and decontamination for ambulance services provided to the enrollee on 
April 7, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane. 
 
You asked the Plan to pre-approve Abraxane. You say that the enrollee needs to start treatment as soon as 
possible. The Plan denied your request. The Plan says the enrollee does not have a hypersensitivity reaction to 
conventional Taxol, or Taxotere; or a documented contraindication to standard hypersensitivity premedications. 
 
Medicare covers 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 
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 Abraxane. Our physician reviewer 
found that the enrollee has stage IV lung cancer. The Plan requires a hypersensitivity reaction to conventional 
Taxol, or Taxotere; or a documented contraindication to standard hypersensitivity premedications before they 
will approve the requested drug. In this case, the enrollee has not tried and failed the Plan?s requirements. 
There is no documentation indicating that the Plan?s required drugs would likely be less effective, or 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 Abraxane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Abraxane.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
June 23, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care and the services 
were ordered by an out of 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 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 out of network physician services provided to the enrollee on 
June 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered when purchased from a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.  
 
Benefits for Prolia 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxycodone acetaminophen. 
 
You asked the Plan to pre-approve these services. You say that hydrocodone has provided no relief. The Plan 
denied your request. The Plan says self-administered drugs are not covered. 
 
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 oxycodone acetaminophen.  
 
Benefits for these services 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: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer, Vertiflex device 
(22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the enrollee does not want to have such a 
significant surgical procedure at this time when an FDA approved minimally invasive treatment option is 
available. The Plan denied your request. The Plan says this service is considered experimental and 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Superion interspinous spacer, Vertiflex device (22869).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee 
has reached his maximum potential from a restorative therapy program. 
 
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 continued services. Our physician 
reviewer found that there are no records to substantiate skilled nursing needs. Regarding rehab services, the 
enrollee is at a moderate assist level for transfers. He 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an acupuncture visit received on July 29, 2020. 
 
You asked the Plan to pay for the visit. You say that you benefited from continuing care. The Plan denied your 
request. The Plan says the benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the enrollee has already reached the 12 visit limit. 
Therefore, we decided that the Plan does not have to pay for an acupuncture visit received on July 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services received on July 13, 
2020. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you have never paid a co-
pay before for these services. The Plan denied your request. The Plan says the copayment applied correctly in 
this case. 
 
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 $35 
copayment for outpatient hospital services.  
 
You have been asked to pay a $35 copayment for the laboratory services. These services fall within the 
outpatient hospital 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 the 
laboratory services received on July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cardiomems system for the enrollee. 
 
You asked the Plan to pre-approve a Cardiomems system. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that this service is considered experimental and 
investigational. 
 
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 Cardiomems system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. In 
this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in 
only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns 
have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the 
CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current 
guidelines for the treatment of heart failure. Thishe device should still be considered experimental or 
investigational. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a 
Cardiomems system. 
 
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 Cardiomems system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Cardiomems system for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for additional reimbursement for ambulance PPE and 
decontamination (HCPCS A0999) provided to the enrollee on April 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 payment for the actual ambulance transport represents payment in full. 
 
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 A0999 is "unlisted ambulance service." 
 
We find that HCPCS code A0999 is not supported in the medical record. Specifically, the payment for this 
code is included in the payment for the main ambulance codes. 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 additional reimbursement for ambulance PPE and decontamination (HCPCS A0999) provided 
to the enrollee on April 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition. 
 
You asked the Plan to pre-approve the requested services. You say that the goal is for the enrollee to reach 
optimum serum albumin levels for at least three months. The Plan denied your request. The Plan says the 
enrollee does not have any medical conditions preventing eating or digestion. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
We looked at the file and the rules. The records do not show that the enrollee has a functioning gastrointestinal 
tract that, due to pathology to, or non-function of the structures, cannot maintain weight and strength 
commensurate with her general condition. The items you asked the Plan to pre-approve are nutritional 
supplements. Therefore, we decided that the Plan does not have to pre-approve intradialytic parenteral 
nutrition.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick Urinary Collection System. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a Purewick Urinary Collection 
System.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on March 26, 
2019. 
 
You asked the Plan to pay for the services. You say that the claim was initially submitted within timely filing 
guidelines. The Plan denied your request. The Plan says the corrected claim was received outside of the 
timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until June 20, 2020. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for imaging services provided to the enrollee on March 26, 2019.
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 these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has pain related to right 
knee osteoarthritis. She has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Synvisc-One 
is not reasonable 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 Synvisc-One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye exam (refractions) with an out-of-network 
provider. 
 
You asked the Plan to pre-approve the eye exam. You say that the service is medically necessary. The Plan 
denied your request. The Plan says eye exams are only covered when received from in-network providers. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed by contract providers. 
 
We looked at the file and the Plan's rules. The provider requested to perform the services is not contract with 
the plan. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an eye exam (refractions) with an 
out-of-network provider.