Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95811). 
 
You asked the Plan to pre-approve the sleep study. You say that the sleep study is medically necessary. The 
Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan follows Medicare rules. Medicare rules say that sleep studies are covered when medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the sleep study. Our reviewer says that 
the sleep study is not medically necessary. Our physician reviewer found at this time, there are no cognitive or 
medical comorbidities that support medical necessity for an in-lab sleep study. A Home Sleep Study would be 
appropriate. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95811).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hospital bed. 
 
You asked the Plan to pre-approve the hospital bed. You say that the enrollee's bed is being taken and that she 
needs another one to replace it. The Plan denied your request. The Plan says the enrollee does not appear to 
have a medical condition that requires positioning of the body. The Plan says that the enrollee is having falls 
due to balance issues, which indicates that she is up and ambulatory. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical condition which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration.  Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 hospital bed. Our reviewer says that 
the criteria for coverage of a hospital bed have not been met. Our physician reviewer found there is no specific 
clinical rationale for the requested item. The enrollee is ambulatory with a walker. She does not have a cardiac 
or pulmonary condition. The enrollee does not require positions which are not feasible in a normal bed to 
alleviate pain, nor does she require an immediate change in body position to alleviate pain. The records 
provided do not show that the enrollee has a covered indication for a hospital bed.  
 
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 hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a hospital bed.
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 will require another 3-4 
weeks of acute management of his medical complexities. The Plan denied your request. The Plan says the 
enrollee's hospital course has not been completed. 
 
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 physician 
reviewer found that the enrollee was admitted to the current acute care facility with obstructive shock from 
pulmonary embolism and bacteremia. He was treated with mechanical ventilation, wound treatment, 
antibiotics, and IV fluids. His atrial fibrillation was treated and monitored, and he received blood transfusion. 
He was extubated and currently still requires ongoing telemetry, basic wound care, nutrition support, and 
ongoing antibiotics. Recently worsening leukocytosis was noted, and continued workup is needed. The enrollee 
appears to be unstable and is still requiring additional acute care services (likely less than 25 days) to continue 
treatment, workup, and monitoring, which he can complete at the current facility. The enrollee does not require 
services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH 
services will be considered not medically necessary at this time. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 7, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you feel that the copayment 
is not warranted. 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 $300 
copayment for ambulance services.  
 
You have been asked to pay a $300 copayment for ambulance services. Ambulance services fall within the 
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 ambulance services 
provided on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for allergen immunotherapy provided on 
January 17, 2020, and January 28, 2020. 
 
You asked the Plan to waive the copayments for allergen immunotherapy. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment per visit to a specialist. 
 
You received allergen immunotherapy on January 17, 2020. Therefore, you are responsible to pay the allowed 
amount of $10.36.   
 
You received allergen immunotherapy on January 28, 2020. Therefore, you are responsible to pay the allowed 
amount of $10.36.   
 
The total amount you owe is: $20.72.  
 
You have been asked to pay the total copayment amount of $20.72 for allergen immunotherapy. Allergen 
immunotherapy falls within the physician/practitioner services, including doctor's office visits 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 copayments for allergen immunotherapy provided on January 17, 2020, and 
January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 4, 2020. 
 
You asked the Plan to pay for the laboratory 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. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory test at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on May 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an X-ray provided on June 8, 2020. 
 
You asked the Plan to waive the copayment for an X-ray. You say that you already paid the copayment for the 
office visit and disagree with the additional 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 $45 
copayment for X-rays.  
 
You have been asked to pay the allowed amount of $40.67, which is less than the $45 copayment for an X-ray. 
An X-ray 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 an X-ray provided on June 8, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Triluron (J7332). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says this requirement encourages the enrollee to try the Plan's preferred drug(s), which 
is/ are just as effective: Monovisc and Orthovisc. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the enrollee has not trialed one viscosupplemental treatment such as Orthovisc and Monovisc. Step 
therapy, as outlined by the plan, requires that one of these be trialed first. The documentation does not outline 
contraindications or reasons these medications were not considered. Without the support of the documentation, 
Triluron is not approved as step criteria have not been met.
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Triluron (J7332).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane injections (J7318) 
 
You asked the Plan to pre-approve Durolane injections. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the member does not have documented physical therapy and or/ 
pharmacologic therapy for at least 6 weeks, therefore injection of the left knee is denied. 
 
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 Durolane injections. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the patient has not met criteria of an 
inadequate response with physical therapy and/or pharmacotherapy for at least 6 weeks. The documentation 
does not support that the requested drug is medically reasonable or necessary for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Durolane injections (J7318)
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you 
received from April 15, 2020, to May 15, 2020. 
 
You asked the Plan to waive the copayment for the SNF services. You say that you had to stay in the facility 
longer than expected due to the quarantine. The Plan denied your request. The Plan says you were charged this 
copayment correctly. 
 
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 $0 
copayment for days 1-20 and a $50 copayment per day for days 21-100 for skilled nursing facility care.  
 
Records show that you were in the SNF for a total of 30 days.  For the first 20 days, you were charged a $0 
copayment per day in accordance with your contract.  For the remaining 10 days, you were charged a 
copayment of $50 per day, for a total of $500.  This copayment applies regardless of the reason for the length 
of your stay. 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 skilled nursing facility (SNF) services you 
received from April 15, 2020, to May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consult to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve an out of network office consult. You say that the in-network providers will 
not give you stem cell therapy. The Plan denied your request. The Plan says review of the medical records does 
not support the medical need for an office visit with an out of network neurologist. 
 
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 consult at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
consult to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve the genetic testing services. You say that the requested testing is medically 
necessary and was denied incorrectly. The Plan denied your request. The Plan says the requested genetic tests 
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 the genetic testing services. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is a 50-year-old woman with a history of Other psychoactive 
substance dependence, Major depressive disorder, obsessive-compulsive disorder, Chronic pain syndrome, 
Low back pain, and Other disorders of peripheral nervous system. Our physician reviewer found that the 
records provided do not support the medical necessity for the genetic testing being requested.  
 
 
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 services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genetic testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum erection device. 
 
You asked the Plan to pre-approve the device. You say that this would make a positive impact on your life. The 
Plan denied your request. The Plan says this is not eligible for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that vacuum erection devices (L7900) are not 
covered. 
 
The requested device is statutorily not covered. 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 a 
vacuum erection device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 4KScore testing provided on February 15, 2020. 
 
You asked the Plan to pay for the 4KScore testing. You say that this is a proven test and should be covered. 
The Plan denied your request. The Plan says this test is noncovered by Medicare. 
 
The Plan follows Medicare rules. Medicare rules say that 4KScore testing may be covered when the criteria 
listed above 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 pay for the 4KScore testing. Our reviewer says that 
the documentation does not show the criteria are met. Our physician reviewer found the lab provider did not 
submit any clinical information from the enrollee's medical record to support this testing meets criteria. 
 
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 4KScore testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the 4KScore testing provided on February 15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received from June 3, 2020, to July 20, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered by Medicare. 

The Plan must follow Medicare rules. Medicare rules say that the above listed individuals and entities 
frequently attempt to enroll in Medicare, but are not eligible to do so. 
 
We looked at the file and Medicare rules. The services in question were provided to you by a licensed 
professional counselor. Licensed professional counselors are not eligible to enrollee in the Medicare program. 
Payment cannot be made to a provider who is not enrolled in the Medicare program. 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 the services you received from June 3, 2020, to July 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. 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 weakness and falls. Your 
medical problems are stable. There are no identified problems that need inpatient medical management. 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. The medical 
record supports a need for physical and occupational therapy but it does not support a need for an intensive 
rehabilitation therapy 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. Our physician reviewer 
found that your condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0428, A0425) 
received on May 14, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. The Plan denied your request. The 
Plan says you were charged this cost sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $265 copayment per date of service. The enrollee had 1 ambulance trip on May 14, 2020. The Plan 
charged the enrollee $265 for these services. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay when enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ambulance services (A0428, A0425) received on May 14, 2020.