Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient surgery services provided
from December 20, 2019 to January 14, 2020.
You asked the Plan to waive the copayments for the outpatient surgery services. You say that you feel you
should not be responsible for this cost share amount and you would like the Plan to reconsider your request.
The Plan denied your request. The Plan says you received outpatient surgery on the dates of service at issue in
this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
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
copayment for Outpatient surgery.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient
surgery services in an outpatient hospital facility on December 20, 2019, December 30, 2019, January 7, 2020,
and January 14, 2020. You have been asked to pay a $313.65 copayment for the December 20, 2019, December
30, 2019, and January 14, 2020 dates of service. You have been asked to pay a $321.62 copayment for the
January 7, 2020 date of service. The outpatient surgery services fall within the Outpatient surgery benefit
category. This means that you have been asked to pay the correct amounts 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 the outpatient surgery services provided
from December 20, 2019 to January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthoses provided on November 1, 2019.
You asked the Plan to pay for the ankle foot orthoses (L1971). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says no medical records were received to support the diagnosis on the submitted order, therefore the billed codes cannot be supported.
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. There are no medical records from the ordering physician supporting medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the ankle foot orthoses (L1971) have not been met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthoses provided on November 1, 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 Synvisc-One. You say that you would like the plan to reconsider their denial
The Plan denied your request. The Plan says the requested drug requires step therapy criteria.
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 documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found documentation submitted includes chart notes. The documentation submitted does not support
that the enrollee has had prior treatment, contraindication, or intolerance to Monovisc and Orthovisc. The
prescriber does not state why the alternatives required by the Plan would not be as effective for the enrollee as
the requested drug; and/or (2) would have adverse effects for the enrollee. Therefore, an exception to the step
therapy criteria is not supported.
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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on December 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
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 lab tests provided on December 11, 2019 by an out of network (OON) provider.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital for a urinary tract infection, Non-ST-elevation myocardial infarction and renal injury following a recent CoViD-19 infection. 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 LTC 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 5, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says there is no valid physician order for the orthosis.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physician order for the items at issue in this
appeal. The record does not contain a valid physician order for the orthosis provided in this case. Therefore, we
decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 5, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
December 27, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be
responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct
cost sharing 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 $90
copayment for each Medicare-covered emergency room visit.
You have been asked to pay a $90 copayment for the emergency room visit. The 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 the
emergency room visit provided on December 27, 2019.
Your complaint about the home health provider's error is not a valid appeal for medical coverage. This part of
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
February 7, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you cannot afford this
bill. The Plan denied your request. The Plan says that the cost share applied appropriately.
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 $250
copayment for per trip for Medicare-covered ambulance services.
You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls
within the Medicare-covered ambulance 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 ambulance transport provided on February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (CPT 97014) provided to the enrollee from May 28, 2019 to July 23, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says only spinal manipulation is a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services (CPT 97014) provided to the enrollee from May 28, 2019 to July 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Hyalgan injection series of 3, 20 mg/2ml per
syringe.
You asked the Plan to pre-approve Hyalgan injections. You say that the requested Hyalgan injections are
medically necessary. The Plan denied your request. The Plan says the requested Hyalgan injections are
medically necessary. The Plan also says that services that are not medically necessary are not covered.
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 Hyalgan injections. Our reviewer says
that the requested Hyalgan injections are not medically necessary. Our physician reviewer found the provided
documentation does not show that the enrollee trialed and failed conservative treatment. The reviewer also
found that the Hyalgan injections are not safe and effective for the enrollee. Therefore, the reviewer did not
find the requested injections to be 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 Hyalgan injections have not been met. Therefore, we decided that the Plan does
not have to pre-approve the Hyalgan injection series of 3, 20 mg/2ml per syringe.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on January 16, 2020 to January 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 physical therapy services provided on January 16, 2020 to January 30, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 15,
2019 through November 30, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received inpatient hospital care from November 15, 2019 through November
30, 2019. You were asked to pay a $250 copayment per day for days 1-7 for inpatient hospital care. However,
you have a $4,500 out-of-pocket maximum and the claim in question only applied $1,571.24 out of $1,750 that
should have applied. Your out-of-pocket maximum was met with this claim. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for inpatient hospital care from November 15, 2019 through November 30, 2019
provided by an in-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.
You asked the Plan to pre-approve Zilretta. You say that you want the enrollee to have this injection for good
pain relief. The Plan denied your request. The Plan says this drug is not approved for repeat use.
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 Zilretta. Our reviewer says that the drug
is not medically necessary. Our physician reviewer found the provider is requesting an intra-articular injection
of the right knee. The provider does not discuss weight loss, or why other types of intra articular steroids
cannot be tried. The enrollee received Zilretta administration into the left knee based on 05/24/2019 and
10/17/2019 procedure notes. Office notes, exams of the knee, and a 10/2018 magnetic resonance imaging of the
right knee do not diagnose osteoarthritis.
Per the FDA approved prescribing information, Zilretta is indicated for the management of knee pain due to
osteoarthritis and is not intended for repeat administration. It can only be used once per knee per lifetime. In
12/2019 there was a package label change that now states the safety and efficacy of repeat Zilretta
administration has not been demonstrated, based on a single phase 3 study. However, this provider needs to
clarify which knee was injected as the office notes indicate issues with the right knee, but the procedure note
says the left knee. The provider does not provide clarification of which knee the injection has previously been
given. Therefore, the service with this medication is not medically reasonable or 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to
pre-approve Zilretta.
Appeal type: Home Health
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say to qualify for home health services, the patient must be: 1. Confined to the home; 2. Under the care of a physician or allowed practitioner; 3. Receiving services under a plan of care established and reviewed by a physician; 4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) continuing occupational therapy. You can find this rule at 42 CFR Section 409.42. The rules say that eligibility for the home health benefit will be determined based on the certifying physician's records. If the enrollee was directly admitted to home health from an acute or post-acute care facility, the facility records may be used instead. The medical records for the enrollee must contain information that justifies the referral for home health services. The certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face encounter visit. You can find these rules in the Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1, 30.5.1.1, and 30.5.1.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 25, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reyvow.
You asked the Plan to pre-approve Reyvow. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Reyvow.
Benefits for Reyvow 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment outpatient hospital services (77065, 88305, A4648, 19081) provided January 31, 2020.
You asked the Plan to waive the copayment the outpatient services. You say that you did not know the facility that provided the service was an outpatient hospital facility. The Plan denied your request. The Plan says 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 $150 copayment for Outpatient Hospital services. You have been asked to pay a $150 copayment for the outpatient services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment outpatient hospital services (77065, 88305, A4648, 19081) provided January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the eyes received on February
12, 2020.
You asked the Plan to waive the copayment for the scan. You say that the plan should reconsider payment. The
Plan denied your request. The Plan says the copayment was processed correctly according to your benefits and
the services rendered.
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 $275
copayment for advanced imaging services.
You have been asked to pay a $275 copayment for the scan. The scan falls within the advanced imaging
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 a CT scan of the eyes
received on February 12, 2020.