Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy visits. 
 
You asked the Plan to pre-approve 6 additional physical therapy visits. You say that physical therapy is 
necessary in order to optimize neurological functioning and recovery status post emergent neurosurgical 
intervention for cervical spinal cord injury. The Plan denied your request. The Plan says the additional visits 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 6 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the unique skills of a professional therapist are 
not required to safely and effectively provide ongoing treatment. 
   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA is covered when the above criteria are met. 
 
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 RFA. Our reviewer says that the 
requested RFA is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer 
found that the enrollee had 2 diagnostic MBBs that only achieved 60% pain relief. This does not meet the 
accepted criteria of 80% pain relief to demonstrate that the facet joints are the pain generators. 
 
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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on February 25, 2020.
You asked the Plan to waive the copayment for a breast ultrasound. You say that you have never been charged for a preventative breast exam before and 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 a $100 copayment for diagnostic procedures and tests provided at an outpatient hospital facility. The medical records show that you received a breast ultrasound on February 25, 2020 at an outpatient hospital facility. Breast cancer screenings do not include breast ultrasounds. Therefore, you are responsible to pay the $100 copayment. You have been asked to pay a $100 copayment for a breast ultrasound. A breast ultrasound falls 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 copayment for a breast ultrasound provided on February 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Euflexxa for the enrollee. 
 
You asked the Plan to pre-approve Euflexxa. You say that the enrollee's needs this for primary osteoarthritis of 
both knees. The Plan denied your request. The Plan says that they did not receive documentation supporting the 
medical necessity for a step therapy exception. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically reasonable and necessary for the enrollee in this case. 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. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria 
for Euflexxa. 
 
 
 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
February 1, 2019 to February 5, 2019. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this bill is a financial 
burden. 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 $250 
copayment per day, days 1 to 7 at an in-network inpatient hospital.  
 
You have been asked to pay a $250 copayment for the inpatient hospital stay. ($250 x 4 days = $1,000). The 
inpatient hospital stay falls within the ?Inpatient hospital care? benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the inpatient hospital stay provided on February 1, 2019 to February 5, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ENTYVIO. 
 
You asked the Plan to pre-approve ENTYVIO. You say that the requested medication is necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy 
exception has 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 ENTYVIO. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the review has determined that the Plan 
requires a trial of drug Inflectra or RENFLEXIS before they will approve the requested drug. In this case the 
enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the 
Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
     
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ENTYVIO have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ENTYVIO.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the medical eye exams and the injections provided on March 16, 2020 and March 30, 2020.
You asked the Plan to waive the cost share for the medical eye exams and the injections. You say that you cannot afford the cost of the injections that your doctor says are necessary.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 $10 copayment for Medicare-covered vision services at an in-network specialist's office and 20% coinsurance for preferred and non-preferred chemotherapy drugs at an in-network specialist's office. You have been asked to pay a $10 copayment for each of the medical eye exams. You have also been asked to pay $13.71 which is 20% of the allowed amount for each of the injections. The allowed amount is $68.54 ($68.54 x 20% = $13.71). The medical eye exams fall under the "Vision care" benefit category. The injections fall 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 waive the cost share for the medical eye exams and the injections provided on March 16, 2020 and March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the follow up visit. You say that you would like reconsideration because it 
is imperative that the provider see you to follow up for further programming and adjustments. The Plan denied 
your request. The Plan says this care may be rendered in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider at issue in this case is not a network provider with the Plan. 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 follow up visit. Our reviewer says that you have a routine degenerative 
spine condition so you may safely follow up with an in-network provider. Our physician reviewer found there 
is no need for you to return to the out-of-network surgeon. 
 
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 follow up visit have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve the follow up visit. Therefore, we decided that the Plan 
does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to pay for the skilled nursing services provided on February 1, 2020. We decided 
that the Plan does not have to pay for the skilled nursing services provided from February 2, 2020 to February 
29, 2020.  
 
You asked the Plan to pay for the skilled nursing services provided from February 1, 2020 to February 29, 
2020. You say that the services which the enrollee required and received are coverable under the Medicare Act. 
The Plan says that the enrollee's condition no longer required daily skilled services at an inpatient SNF level of 
care. 
 
We decided that the Plan has to pay for the skilled nursing services provided on February 1, 2020.  
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before January 31, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pay for the skilled nursing services provided on February 1, 2020.  
 
We also decided that the Plan does not have to pay for the skilled nursing services provided from 
February 2, 2020 to February 29, 2020. 
 
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 pay for the skilled nursing services provided from 
February 2, 2020 to February 29, 2020. Our reviewer says that the enrollee did not meet the Medicare criteria 
for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required 
the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily 
skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the skilled nursing services provided from February 2, 2020 to February 29, 
2020 have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing 
services provided from February 2, 2020 to February 29, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 16, 2020 
through February 20, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says that the stay is not medically necessary. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the patient met criteria for admission based on underlying comorbid conditions, need for 
intravenous (IV) antibiotics and interventional procedure for drain replacement, and due to electrolyte and 
cardiac instability. Our doctor found that it was reasonable to expect that at least two midnights would be 
necessary at the time of admission. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 16, 2020 through February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable


We decided that the Plan has to pay for frames (V2020) and trifocal lenses (V2303) purchased March 4, 2019. 
 
You asked the Plan to pay for the vision services. You say that you asked the provider before cataract surgery 
to confirm they were in network, which they did. You believe this claim should be processed and payment 
made to you, since you have paid the provider. The Plan denied your request. The Plan says that the enrollee's 
plan is "exam only". There are no benefits for eyewear. 
 
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 one pair of eyeglasses or contact lenses after each cataract surgery. The health plan 
contract also says that there is $0 copayment for eyewear (post cataract surgery) both in-network and out-of-
network, at all place of treatment.  The plan confirmed that the enrollee received cataract surgery January 7, 
2019 and January 21, 2019.. 
 
We looked at the file and the Plan's rules. The Plan covers one pair of eyeglasses or contact lenses after each 
cataract surgery. Covered eyeglasses after cataract surgery includes standard frames and lenses as defined by 
Medicare; any upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive 
lenses, or anti-reflective coating). Based on this information, we decided that the Plan's rules for coverage of 
the vision services have been met. Therefore, we decided that the Plan has to pay for frames (V2020) and 
trifocal lenses (V2303) purchased March 4, 2019.  
    
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 Plasma-Based Comprehensive Genomic 
Profiling testing provided on January 20, 2020 billed with multiple CPT codes. 
 
You asked the Plan to pay for the Guardant 360 testing as billed. You say that this should not be denied as 
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan 
says on review, it was found that no payment can be made for this testing because the provider is unbundling 
when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one 
unit of code 81479 should be reported with the appropriate DEX Z-code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based 
Comprehensive Genomic Profiling testing provided on January 20, 2020 billed with multiple CPT codes.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the comprehensive oral evaluation 
(D0150), panoramic radiographic image (D0330), and the bitewing x-rays (D0274) provided on February 25, 
2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says the coinsurance has been 
applied correctly to the dental services provided. 
 
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 50% 
coinsurance for preventive dental services rendered by an out of network provider. Additionally, you may be 
billed by an out of network provider for any amount greater than the payment made by the Plan to your 
provider. 
 
You have been asked to pay a $323.50 coinsurance (50% x $129 allowed amount and $259 of additional 
charges) for the preventive dental services rendered by the out of network provider. The additional charge is 
the difference between the allowable amount and the amount the provider billed for this service. You may be 
billed by an out of network provider for any amount greater than the payment made by the Plan to your 
provider. 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 comprehensive oral evaluation (D0150), 
panoramic radiographic image (D0330), and the bitewing x-rays (D0274) provided on February 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's current needs are being met in the acute setting.
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. The enrollee does not require services at the LTACH that are not already available at the current acute care hospital. As the patient appears to be improving, it is expected that acute care services at the current facility will be needed for less than 25 days. There are no services available at the current LTACH that the enrollee requires that are not already covered and available at the current facility. Transfer to a lower level of care in time should be appropriate. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 for the enrollee.