Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for a Medicare Part B drug injection. We 
decided that the Plan does not have to waive the copayment for the administration.  
 
You asked the Plan to reduce the cost-sharing charges for a Medicare Part B drug injection and to waive the 
copayment for the administration. You say that you were told that you would only owe a $25 copayment. The 
Plan says that the claims were processed correctly and you are being charged the correct amount. 
 
We decided that the Plan has to reduce the cost-sharing charges for a Medicare Part B drug injection 
from $1,259.37 to $1,239.22.  
 
The Plan contract says that you must pay 20% coinsurance for Medicare Part B drugs. The allowed amount is 
$6,196.10 and 20% of that is $1,239.22. 
 
The Plan says that you must pay $1,259.37, however, you cannot be asked to pay more than 20% coinsurance 
for Medicare Part B drugs. Therefore, we decided that the Plan has to reduce the cost-sharing charges for a 
Medicare Part B drug injection from $1,259.37 to $1,239.22.  
 
We also decided that the Plan does not have to waive the copayment for the administration. 
 
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 $175 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. 
 
You received the administration of a Medicare Part B drug on December 17, 2019, at an outpatient hospital 
facility. Therefore, you are responsible to pay the allowed amount of $61.64, which is less than the $175 
copayment. Therefore, we decided that the Plan does not have to waive the copayment for the administration.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90791) performed on 
April 1, 2019. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that the claim was untimely 
submitted due to you not receiving proper notice of the enrollee's benefit determination from the providing 
facility. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for a psychiatric diagnostic evaluation was not filed until August 27, 2020. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90791) 
performed on April 1, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee tested positive for COVID-
19 on January 27, 2021. She currently resides in an assisted living facility and is wheelchair-bound. She is 
asymptomatic and has normal oxygenation. She needs minimal assist with transfers and mobility. She has no 
skilled nursing needs. She does not require skilled nursing on a daily basis. She has skilled therapy needs but 
does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the 
necessary services on an inpatient basis at the SNF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
COVID-19 pneumonia. Medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95940, 95938, 95955, 95910) 
provided January 23, 2019. 
 
You asked the Plan to pay for the neuromonitoring services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the neuromonitoring services was not filed until August 11, 2020. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95940, 95938, 95955, 
95910) provided January 23, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department services (99284) and 
electrocardiogram (93010) provided on July 15, 2020. 
 
You asked the Plan to pay for the emergency department services and electrocardiogram. You say that you 
would like reconsideration because the services provided were medically necessary. The Plan denied your 
request. The Plan says manifestation codes cannot be listed as the primary, first listed, or principal diagnosis on 
a claim because each describes a manifestation of some other underlying disease, not the etiology or disease 
itself. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes 99284 and 93010 are not supported in the record. Specifically, this claim was billed 
with the manifestation code as the primary diagnosis. The underlying condition should be listed first, followed 
by the manifestation. Based on this information, we decided that Medicare rules for coverage of the emergency 
department services and electrocardiogram have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency department services (99284) and electrocardiogram (93010) provided on July 
15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta. 
 
You asked the Plan to pre-approve the Vyzulta. You say that the enrollee is stable on Vyzulta, and needs to 
continue treatment. The Plan denied your request. The Plan says this medication is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vyzulta.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Zyclara 3.75% Cream. 
 
You asked the Plan to pre-approve the Zyclara 3.75% Cream. The Plan denied your request. The Plan says this 
drug is not covered for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Zyclara 3.75% Cream.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on October 23, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you did not see a provider. 
You say that you just saw a nurse practitioner. The Plan denied your request. The Plan says the correct 
copayment has been 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 $35 
copayment for physician/practitioner services/specialist visit.  
 
You have been asked to pay a $35 copayment for specialist services. A nurse practitioner is considered a 
specialist; therefore, the correct copayment has been applied. Specialist services fall within the 
physician/practitioner services/specialist visit 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 specialist services provided by a participating provider on October 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing care. 
 
You asked the Plan to pre-approve the continued skilled nursing care. You say that the enrollee is not safe at 
home. You also say that the enrollee needs care 24 hours a day, 7 days a week. The Plan denied your request. 
The Plan says the enrollee no longer requires daily skilled services, and the continuation of SNF care is not 
medically necessary. 
 
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 the continued skilled nursing care. Our 
reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found 
the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 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. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of the continued skilled nursing care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee will require better pain control and 
rehabilitation to decrease risk of future falls and serious injury. The Plan denied your request. The Plan says 
that care can be provided at a lower level of care. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (HCPCS G0483) provided to the enrollee on 
July 23, 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 the documentation received does not include definitive laboratory results for 22 or more drug 
classes to support the coding criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of HCPCS code G0483 is Drug test(s), definitive, utilizing (1) 
drug identification methods able to identify individual drugs and distinguish between structural isomers (but 
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any 
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods 
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all 
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or 
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations 
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 
or more drug class(es), including metabolite(s) if performed.
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
laboratory report does not include 22 or more definitive drug classes. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing (HCPCS G0483) provided to the enrollee on July 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no documentation showing that the enrollee would benefit from and 
improve with LTACH management. 
 
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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee 
requires that are not available at the health care setting being offered by the health plan. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and able to be furnished safely and effectively only on an inpatient basis. 
 
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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has back pain. There is no 
spinal instability. The requested Superion spacer is considered experimental in nature, as more research is 
needed to show safety and efficacy. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of Zoledronic Acid or a history of osteoporotic fracture is required before Prolia 
can be considered. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found documentation does not support a history of an 
osteoporotic fracture or previous treatment with the plan preferred drug. The record shows no reason the plan 
preferred drug would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve AMITIZA. 
 
You asked the Plan to pre-approve AMITIZA. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve AMITIZA.  
 
Benefits for AMITIZA may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.