Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on August 9, 2018. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges. 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 20% 
coinsurance for DME and related supplies.  
 
You received DME on August 9, 2018. The allowed amount is $68.78 and 20% of that is $13.76.  
 
You have been asked to pay the total coinsurance amount of $13.76 for DME. DME falls within the DME and 
related 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 coinsurance for DME provided on August 
9, 2018.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan 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 the preferred supplements are Orthovisc and Monovisc and don't require prior 
authorization. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not 
trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, 
requires these be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered. Without the support of the documentation, Hyalgan is not approved, as step 
criteria have not been met. 
 
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 Hyalgan for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration (20939). 
 
You asked the Plan to pre-approve bone marrow aspiration (20939). You say that the requested bone marrow 
aspiration (20939) is medically necessary. The Plan denied your request. The Plan says the requested bone 
marrow aspiration (20939) 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 bone marrow aspiration (20939). Our 
reviewer says that the requested bone marrow aspiration (20939) is not medically necessary. Our physician 
reviewer found the enrollee is with prior L4-5 fusion in 2013 and now has worsening pain, sensory deficit and 
abnormal reflexes. Imaging demonstrates adjacent segment disease above the fusion at the L3-4 level with 
spinal stenosis. The enrollee has failed conservative therapy. Bone marrow aspiration remains experimental in 
cases of spinal fusion surgery. More research is needed to show the safety and efficacy of bone marrow 
aspiration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration (20939) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bone marrow aspiration (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Medicare Part B drug Fasenra you 
ordered on February 20, 2020. 
 
You asked the Plan to waive the coinsurance for Fasenra. You say that no one ever told you about the 
coinsurance and you cannot afford this.  You say that you have not yet gone to your doctor's office to have this 
drug administered. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  
The plan confirmed that the pharmacy contacted you to get your approval to ship this drug to your doctor's 
office and your wife supplied the approval.  The drug is sitting at your doctor's office waiting to be 
administered. Since you ordered this drug, you are responsible for the coinsurance. 
 
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 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for Fasenra. Fasenra falls within the Medicare Part B 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 waive the coinsurance for the Medicare Part B drug 
Fasenra you ordered on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a visual field exam (92083) performed on 
May 19, 2020. 
 
You asked the Plan to waive the deductible for a visual field exam. You say that you never had a deductible 
before. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
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 there is a $250 deductible for outpatient services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner services, including doctor's office visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $250 deductible for outpatient services. This cost sharing is a 
contractual obligation that had not been met at the time a visual field exam was received on May 19, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for a visual field exam (92083) 
performed on May 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve HYALGAN Supartz (J7321). 
 
You asked the Plan to pre-approve the HYALGAN Supartz. The Plan denied your request. The Plan says the 
information submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the HYALGAN Supartz. Our reviewer 
says that HYALGAN Supartz is not medically reasonable and necessary. Our physician reviewer found based 
on the medical records provided, you have not tried and failed the required drug(s). Our reviewer also found 
that there is no indication that the Plan's required drug(s) would likely be less effective and/or likely have 
adverse effects for you. 
 
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 HYALGAN Supartz have not been met. Therefore, we decided that the Plan 
does not have to pre-approve HYALGAN Supartz (J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infection control supplies coded S8301 and the Iv tubing 
extension set coded S1015 provided on March 14, 2020. 
 
You asked the Plan to pay for the infection control supplies and the Iv tubing extension set. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items billed are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes S8301 and S1015 are not supported in the medical record. Specifically, these codes 
have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. 
Medicare uses another code for reporting of, and payment of these services. Based on this information, we 
decided that Medicare rules for coverage of the infection control supplies and the Iv tubing extension set have 
not been met. Therefore, we decided that the Plan does not have to pay for the infection control supplies coded 
S8301 and the Iv tubing extension set coded S1015 provided on March 14, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found This enrollee does not require 
skilled nursing service with the specialized skill, knowledge and judgment of a skilled professional nurse 
required to safely and effectively provide medically necessary and reasonable treatment only in a SNF. Her 
medical condition is stable and there is no complex wound care or other SN need. The enrollee's functional 
level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The 
enrollee does not require skilled nursing or skilled therapy services on a daily basis in a SNF and as a practical 
matter  this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 
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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the 
SNF from home. From a nursing perspective, the enrollee received oral medications. The enrollee had stable 
vital signs. She used oxygen via nasal cannula at baseline. Regarding rehabilitation services, the enrollee 
received a physical therapy evaluation in the SNF. The enrollee was at a stand by assist to supervision level 
with transfers and she could negotiate her wheelchair and toilet with modified independence.   
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found based on 
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for 
CoViD-19.  The enrollee is not intubated/ventilated.  There is no evidence that the enrollee requires 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 the enrollee to the LTACH.  The enrollee can remain at the current ACH until 
such time no acute services are required.  The enrollee can then be transferred/discharged to a lower level of 
care for any ongoing long term care needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for the services on May 11, 2020, and June 8, 
2020. 
 
You asked the Plan to waive the cost-share for the services. You say that the cost is too high. The Plan denied 
your request. The Plan says the claims were 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 show that you received specialist office services and Aflibercept 1MG injections on May 11, 
2020 and June 8, 2020. You are asked to pay a $40 copayment per date of service for the office services. 
Furthermore, you have been asked to pay 20% coinsurance of the allowed amount for prescription drugs per 
visit. The allowed amount is $1890.06 per visit. The total you owe per visit is $378.01 ($1890.06 x 20% = 
$378.01). Your EOC states, enrollees must pay 0% of the total cost for Medicare-covered Part B prescription 
drugs, including chemotherapy drugs and enrollees must pay a $40 copay for each Specialist visit. 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 cost-share for the services on May 11, 2020, and June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a paring or cutting of benign lesion (11056) 
performed on May 22, 2020. 
 
You asked the Plan to waive the deductible for a paring or cutting of benign lesion. You say that this service 
was not provided to you. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
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 there is a $750 deductible for additional physician or specialist services 
performed on the same day in the physician?s office.  
 
In this case, medical records from the provider show that a paring or cutting of benign lesion was performed on 
May 22, 2020. The item or service you asked the Plan to waive the deductible for falls within the benefit 
category ?Podiatry services.? The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $750 deductible for additional physician or specialist services performed on the same day in the 
physician?s office. This cost sharing is a contractual obligation that had not been met at the time a paring or 
cutting of benign lesion was performed on May 22, 2020. Therefore, we decided that the Plan does not have to 
waive the deductible for a paring or cutting of benign lesion (11056) performed on May 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on October 3, 2019. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on October 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 11, 
2019, through February 18, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this is not durable medical equipment and was not delivered to the member's home. The Plan denied your 
request. The Plan says S codes are not payable by Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) 
provided on October 11, 2019, through February 18, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a PET scan provided to the enrollee on February 6, 2020. 
 
You asked the Plan to pay for the scan. You say that this is medically necessary. The Plan denied your request. 
The Plan says that this was not reported with an appropriate diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 pay for the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the scan was done as a 
follow-up after treatment to a PET/CT of 11/4/19. The scan was indicated and necessary to compare to prior 
exam to determine treatment efficacy. While a specific cell type of cancer is not listed in the report the dictated 
history of "colon cancer" almost invariably reflects adenocarcinoma of the colon. 
 
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 scan have been met. Therefore, we decided that the Plan has to pay for a 
PET scan provided to the enrollee on February 6, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ascent injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that the enrollee will benefit from this injection to 
protect, cushion, provide lubrication, and reduce inflammation. The Plan denied your request. The Plan says 
this injection is currently under investigation. 
 
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 injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the Ascent injections at issue in this case are medically 
reasonable and necessary. Human amniotic fluid injections for the treatment of knee osteoarthritis are unproven 
and cannot be considered safe and effective. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ascent injection for the enrollee.