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

 
We decided that the Plan has to partially waive the copayment for the specialty physician office visits provided 
between June 24, 2020, and August 31, 2020. We decided that the Plan does not have to waive the coinsurance 
for the drug injection services.  
 
You asked the Plan to waive the copayment for specialty physician office visits and drug injection services. 
You say that you should not have to pay the coinsurance or copayment. The Plan says that specialty office 
visits provided in-network are subject to a $35 copayment amount and Part B drugs are subject to a 20% 
coinsurance amount. 
 
We decided that the Plan has to partially waive the copayment for the specialty physician office visits. The 
Plan denied your request, stating that in-network specialty office visits are subject to a $35 copayment. 
However, we found that page 82 of the Plan?s 2020 EOC shows that a $30 copayment is required for a 
specialty office visit provided in-network. Therefore, the Plan is required to adjust the copayment amount for 
the specialty physician office visits provided to you between June 24, 2020, and August 31, 2020. 
 
We also decided that the Plan does not have to waive the copayment for drug injection services. 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 Part B drug services. The amount that you paid was equal to or less than 20% of the cost of the 
drug injection services. Therefore, we decided that the Plan does not have to waive the copayment for the drug 
injection services provided to you between June 24, 2020, and August 31, 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 Juluca. 
 
You asked the Plan to pre-approve Juluca. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not have Part D drug coverage under this contract. The 
Plan says that the requested drug is intended to be self-administered. 
 
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 Juluca.  
 
Benefits for Juluca 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement cochlear implant supplies provided. 
 
You asked the Plan to pay for the replacement supplies. You say that the enrollee has had a cochlear implant 
placed. You were informed that replacement was needed and provided this without delay. You say 
this should be covered due to medical necessity. The Plan denied your request. The Plan says despite requests 
for the documentation, no physician order was submitted for the supplies at issue. 
 
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 does not contain a valid physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the replacement cochlear implant supplies provided.
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 outpatient treatment. You say that you have cancer and have been through 3 
surgeries. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this provider is out-of-network with the Plan and you can be treated by an in-network provider within 
the Plan's service area. 
 
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 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. We found no exception that would require 
the Plan to pre-approve these items/services. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Perjeta 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 enrollee is in a clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the drug as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Perjeta for the enrollee.
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 you are about to be released from the hospital, but 
feel inpatient rehabilitation is needed to regain maximum function. The Plan denied your request. The Plan 
says the IRF services you are requesting do not meet the requirements for approval. 
 
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 documentation does not support that the complexity of your nursing, medical and 
rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. Our reviewer found that the documentation does not support that you require at least 3 hours a day, 5 days 
a week, or 15 hours over 7 consecutive days, of therapy services. Our physician reviewer also found that there 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a coronary computed tomography angiography (CCTA) 
scan with calcium scoring. 
 
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 submitted records show that you 
have no history of cardiac symptoms. You are not under consideration for heart catheterization and have not 
had a stress test. The requested CCTA would be for screening purposes, and Medicare does not cover the 
services for that purpose. 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 coronary computed tomography angiography (CCTA) scan with calcium scoring.
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 June 
29, 2018 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not feel 
responsible for the billing negligence. 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 $265 
copayment per day for days 1-7 for in-network inpatient hospital care.  
 
You have been asked to pay a $265 copayment for the inpatient hospital stay. 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 June 29, 2018
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 8, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services (90832). You say that you would like reconsideration 
because the services rendered were medically necessary and it is the responsibility of the facility to verify 
eligibility. The Plan denied your request. The Plan says utilization of network providers is required unless the 
Plan pre-approves out-of-network services in non-emergent situations. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on July 8, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Lightweight Manual Reclining Wheelchair. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Review of the records show that you 
are not at risk for development of a pressure ulcer and are able to perform functional weight shift. Therefore, 
we decided that the Plan does not have to pre-approve a Lightweight Manual Reclining Wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan from the skull to mid-thigh (78815) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve a PET CT scan from the skull to mid-thigh to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide this care. Therefore, coverage criteria has not been met. 
 
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 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the 
skull to mid-thigh (78815) to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded 81519 provided on April 24, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the rendered services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that oncology genetic testing is only covered for certain 
indications. 
 
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 genetic testing. Our reviewer says that 
the documentation does not support that the testing provided was medically reasonable or necessary. Our 
physician reviewer found the enrollee has a left breast cancer that is ER/PR+ and HER2 negative. No 
information on the size of the tumor or number of nodes tested and involved is provided. Without this 
information, coverage criteria cannot be determined. Therefore, the enrollee did not meet criteria for the 
services rendered. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the genetic testing coded 81519 provided on April 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral ultrasound ablation. 
 
You asked the Plan to pre-approve the procedure. You say that this service would help with life-threatening 
cancer. The Plan denied your request. The Plan says medical studies have not proven that this service 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 procedure. Our reviewer says that 
the requested procedure is not considered medically reasonable and necessary in this case. Our physician 
reviewer found MRI-guided transurethral ultrasound ablation (TULSA) in this case is not medically reasonable 
and necessary. The clinical value and effectiveness of magnetic resonance imaging-guided transurethral 
ultrasound ablation (MRI-TULSA) in the setting of recurrent prostate cancer has not been demonstrated in the 
peer-reviewed literature. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transurethral ultrasound ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307, G0480) provided on 
by an out of network (OON) provider. 
 
You asked the Plan to pay for OON laboratory services. You say that these were medically necessary services 
provided in good faith. The Plan denied your request. The Plan says these 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 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 laboratory services (80307, G0480) provided 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity. 
 
You asked the Plan to pre-approve Trulicity. You say that the drug in dispute is medically necessary. The Plan 
denied your request. The Plan says drug coverage through them is limited to only drugs covered under your 
medical benefit. The Plan says that you may have a separate commercial pharmacy benefit or Medicare Part D 
benefit managed by another carrier. 
 
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 Trulicity.
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 enrollee needs the extended care of 
an LTACH. The Plan denied your request. The Plan says the enrollee's needs can be met at the current hospital. 
 
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 records shows that the current short-term acute care hospital can provide for all 
the patient?s present inpatient care needs. The patient is receiving an appropriate level of care in the present 
setting.  Continued care in the short-term acute care hospital is appropriate until the patient is stable to transfer 
to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled 
nursing facility. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has rheumatoid arthritis 
and has failed methotrexate as a single agent and for whom use of Humira is becoming cost-prohibitive. The 
request is for Simponi Aria as a single agent. 
 
Simponi Aria is indicated for rheumatoid arthritis when used in conjunction with methotrexate. There is no 
medical rationale in the submitted records as to why methotrexate cannot be given in conjunction with Simponi 
Aria in this case. 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 Simponi Aria.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the static progressive stretch knee device (E1811) provided 
on August 4, 2020. 
 
You asked the Plan to pay for the static progressive stretch knee device. You say that you would like 
reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says the 
records do not show that the evaluation took place at a qualifying originating site. 
 
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 pay for the static progressive stretch knee device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is insufficient evidence in the documentation of a detailed 
objective physical examination of the patient and knees including measurements of strength, range of motion, 
sensory testing and a gait evaluation that would support the need for this device. There is no evidence of a 
recent injury to the knees or a recent knee surgery. 
 
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 static progressive stretch knee device have not been met. Therefore, we 
decided that the Plan does not have to pay for the static progressive stretch knee device (E1811) provided on 
August 4, 2020.