Persius/hicric huggingface dataset:
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. You say that this is medically necessary. The Plan denied 
your request. The Plan says step therapy requirements have not been 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 Synvisc-One. Our reviewer says that 
the criteria for coverage of Synvisc-One have not been met. Our physician reviewer found the Plan requires a 
trial of Orthovisc and Monovisc before they will approve the requested drug. Based on the medical records 
provided the patient has not tried and failed the required drugs and there is no indication that the required drugs 
would likely be less effective or have adverse effects for the patient. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the family wants the enrollee to go to rehab. You say that you are appealing the denial. The Plan denied your request. The Plan says services can be provided at a lower level of care.
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 there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician or acute rehab nursing care. Our reviewer says that the enrollee's needs can be met in a lower intensity alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections (J0585). 
 
You asked the Plan to pre-approve Botox injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says this use is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox injections. Our reviewer says 
that the use of Botox injections is not supported in this case. Our physician reviewer found Botox injections are 
not FDA-approved for your diagnosis and is not supported by one of the major drug compendia or by clinical 
research. The documentation does not support that Botox is likely to be safe and effective, and otherwise 
reasonable and necessary for you in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Botox injections (J0585).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided March 27, 2020 to March 30, 2020. You asked the Plan to waive the copayment for the inpatient hospital care. You say that you were admitted awaiting the results of a COVID-19 test and if the test was negative you shouldn't have been admitted so the copayment should be waived. The Plan denied your request. The Plan says you were admitted for treatment of pneumonia and the correct copayment 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). Your contract with the Plan clearly says that you must pay a $395 per day copayment for days 1-4 of Inpatient Care. You have been asked to pay a $395 per day copayment for 3 days of inpatient hospital care ($1,185). 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 provided March 27, 2020 to March 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for Leuprolide acetate provided on February 
17, 2020. 
 
You asked the Plan to adjust the copayment for Leuprolide acetate (J9217). You say that the copayment is too 
high. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for Leuprolide acetate (J9217). Leuprolide acetate (J9217) falls 
within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to adjust the copayment 
for Leuprolide acetate provided on February 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bevacizumab for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no support for this combination in the major drug compendia, or in clinical 
research in a CMS-approved medical journal. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has a 
diagnosis of hepatocellular carcinoma. Documentation supports the enrollee received treatment with 
Bevacizumab and Nivolumab.  Review of the literature does not support the use of this medication combination 
treatment. Without the support of the documentation, medical necessity is not determined. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Bevacizumab for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on January 22, 2020. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on March 16, 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 Comprehensive Genomic Profile (CGP) testing (Guardant-360 and NEXT-Generation) 
requires use of CPT 81479. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 12, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because you 
are in-network with Medicare and the Plan. The Plan denied your request. The Plan says utilization of network 
providers is required when possible and available. 
 
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 March 12, 2020 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided March 13, 2020 to 
March 14, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record does not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier Emergency and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided March 13, 2020 to March 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00952) provided on February 20, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because this 
service was medically necessary. The Plan denied your request. The Plan says the required anatomical 
structures for this service are no longer present. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that for Medicare to consider 
coverage and payment for any item or service, the information submitted by the supplier or provider must 
corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage 
criteria have been met. 
 
In this case, the CPT Code Manual definition of code 00952 is anesthesia for vaginal procedures (including 
biopsy of labia, vagina, cervix or endometrium); hysteroscopy and/or hysterosalpingography  
 
We find that CPT code 00952 is not supported in the record. Specifically, the submitted documentation does 
not include any medical records to validate the service at issue. Based on this information, we decided that 
Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia services (00952) provided on February 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ambulance services and inpatient mental 
health care provided on January 5, 2020 through January 12, 2020. 
 
You asked the Plan to waive the coinsurance for the ambulance services and inpatient mental health care. You 
say that you would like reconsideration because the member was removed from the emergency room without 
your authorization. The Plan denied your request. The Plan says the appropriate cost sharing was applied to the 
ambulance charges and inpatient mental health care as outlined in the EOC. 
 
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 $225 per ambulance service and $220 per day for days 1-5 of inpatient mental health services.  
 
The enrollee has been asked to pay $225 for each ambulance trip. The enrollee has been asked to pay $1,100 
for 5 days of inpatient mental health care. 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 coinsurance for 
ambulance services and inpatient mental health care provided on January 5, 2020 through January 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services rendered on April 6, 
2020. 
 
You asked the Plan to waive the copayment for these services. You say that you thought that telehealth services 
had no copayment. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each specialist visit for Medicare-covered services.  
 
Review of the file shows that you received dermatology specialist services on April 6, 2020. You have been 
asked to pay a $35 copayment for these services. These services fall within the specialist visit for Medicare-
covered 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.  
 
The file shows that the services were telehealth; however, the copayment still applies because they were 
specialist services. The Plan contract has a $0 copayment for telephonic services from a licensed clinical social 
worker and certified health coach only. 
 
Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered 
on April 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 24, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because you 
are in-network with Medicare and the Plan. The Plan denied your request. The Plan says utilization of network 
providers is required when possible and available. 
 
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 March 24, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a refractive procedure (92015) performed on June 8, 2020. 
 
You asked the Plan to pay for a refractive procedure. You say that you had understood that a routine vision 
exam would have a $0 copayment. The Plan denied your request. The Plan says refractive procedures are only 
covered when you use a "Select" provider.
 
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 these services are rendered by a "Select" provider. 
 
We looked at the file and the Plan's rules. In this case, the provider who performed the refractive procedure is 
not a "Select" provider. Based on this information, we decided that the Plan's rules for coverage of a 
determination of refractive state have not been met. Therefore, we decided that the Plan does not have to pay 
for a refractive procedure (92015) performed on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 19, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. The records provided do not contain 
documentation of the ordering physician's intent that the tests be performed. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on December 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a breast ultrasound and diagnostic 
mammogram provided on June 9, 2020. 
 
You asked the Plan to waive the copayments for a breast ultrasound and diagnostic mammogram. You say that 
you disagree with the charges because you never paid 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 $40 
copayment for basic imaging services. 
 
The medical records show that you received a breast ultrasound and diagnostic mammogram on June 9, 2020. 
Therefore, you are responsible to pay a $40 copayment per each test. The total amount you owe is: $40 
(copayment) x 2 (diagnostic tests) = $80.   
 
You have been asked to pay the total copayment amount of $80 for a breast ultrasound and diagnostic 
mammogram. A breast ultrasound and diagnostic mammogram fall within the outpatient diagnostic tests and 
therapeutic services and supplies 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 copayments for a 
breast ultrasound and diagnostic mammogram provided on June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 21, 2020 by an 
out of network (OON) provider. 
 
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 were rendered by an out-of-network provider without prior authorization. 
 
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 February 21, 
2020 by an out of network (OON) provider.