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

 
We decided that the Plan does not have to waive the copayment for the lumbar injection provided on March 11, 
2020. 
 
You asked the Plan to waive the copayment for the lumbar injection. You say that the injection was not done 
all they did was the CT scan. You say that you were charged $310 for an injection that wasn't done. The Plan 
denied your request. The Plan says the copayment applied 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 $310 
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, 
including but not limited to hospital or other facility charges and physician or surgical charges. 
 
You have been asked to pay a $310 copayment for the lumbar injection. The lumbar injection falls within the 
"Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers" benefit category. The records show that the lumbar injection was provided. 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 lumbar injection provided on March 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Praluent Pen. 
 
You asked the Plan to pre-approve a Praluent Pen. You say that this is medically necessary. The Plan denied 
your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 
plan. 
 
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 a Praluent Pen.  
 
Benefits for a Praluent Pen 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home services, patient unstable or significant new problem 
requiring immediate physician attention, 60 min. (99350) and physical therapy evaluation (97163) provided 
September 12, 2019. 
 
You asked the Plan to pay for the home health services. You say that the call with the representative and EOB 
does not adequately describe the decision for considering this service as not medically necessary. You request 
review and process the claim for payment. The Plan denied your request. The Plan says the records do not 
support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99350 and 97163 is not supported in the medical record. Specifically, for CPT code 
93350, a home visit cannot be billed by a physician unless the physician was actually present in the 
beneficiary's home. The medical records show the submitted services were performed by a LVN. CPT code 
97163 is appropriate when services are provided by a licensed physical therapist and the member meets criteria 
for home PT services.  Medical records show that the enrollee had a visit by a physical therapy assistant (PTA) 
and completed ambulation and transfer training. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home services, patient unstable or significant new problem requiring immediate physician attention, 60 
min. (99350) and physical therapy evaluation (97163) provided September 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided on January 3, 
2020. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you were misinformed that there 
would be no out-of-pocket cost. You say that you wouldn't have had the operation if you knew of any out-of-
pocket costs. The Plan denied your request. The Plan says the copayment applied 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 $300 
copayment for surgery services at an in-network ambulatory surgical center. 
 
You have been asked to pay a $300 copayment for the cataract surgery. Cataract surgery falls within the 
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers" 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 cataract surgery provided 
on January 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Injectafer. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Injectafer is medically reasonable or necessary for the enrollee. The 
documentation does not support that the Injectafer is safe and effective 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
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 based on review of the medical records, you do not meet the CMS coverage criteria 
for an IRF admission. You are generally medically stable after a SBO and surgery with Debility and no 
evidence of medical or nursing needs in an IRF and your current functional status does not require IRF level of 
therapies. There is no evidence of medical issues that require monitoring by an inpatient rehab physician three 
(3) times a week. The documentation does not support that there is a need for an intensive therapy program 
with 3 hours a day at current level of function and an interdisciplinary approach to rehab care. The IRF 
admission is not medically necessary and also does not meet the CMS coverage criteria. Your rehab needs can 
be safely and effectively met in an alternate, less intense setting such as in a skilled nursing facility (SNF). 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc injections (J7324). 
 
You asked the Plan to pre-approve Orthovisc injections. You say that the Orthovisc injections are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Orthovisc injections 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 orthovisc injections. Our reviewer says 
that the injections are not medically necessary. Our physician reviewer found the provided records do not 
support that all Medicare coverage rules have 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 orthovisc injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Orthovisc injections (J7324).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is functioning 
at/near his baseline. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a 
lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one-hundred twenty (120) visits to an out-of-network 
provider. 
 
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. 
The Plan denied your request. The Plan says there are in-network providers that are available to provide the 
services. 
 
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 remaining 120 visits have been denied as the dialysis center is out-of-network. 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 one-hundred twenty (120) 
visits to an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient psychotherapy services to be provided by a 
Marriage and Family Therapist (MFT). 
 
You asked the Plan to pre-approve the services. You say that this provider understands your situation and 
disability versus a normal therapist. The Plan denied your request. The Plan says the provider is a MFT. The 
Plan states that according to Centers for Medicare and Medicaid Services (CMS) Manual; MFT-s are not 
qualified Medicare providers and are not allowed to bill Medicare, which is your primary insurance. 
 
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 services have not been met. MFTs are not eligible providers 
with Medicare and are not allowed to bill Medicare. Therefore, we decided that the Plan does not have to pre-
approve outpatient psychotherapy services to be provided by a MFT.
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 OON 
provider. 
 
You asked the Plan to pre-approve the medical services. You say that you are requesting an out-of-network 
surgical suite. The Plan denied your request. The Plan says the member is approved for facet injections, but the 
facility you are requesting is an out-of-network surgical suite. The Plan states there are a number of in-network 
health care facilities where the member could receive the services. 
 
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 OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner and seat lift mechanism. 
 
You asked the Plan to pre-approve the items. You say that you are unable to get up from the recliner. The Plan 
denied your request. The Plan says the recliner is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
A seat lift is only covered if the member has severe arthritis of the hip, the seat lift will effect improvement or 
arrest or retard deterioration of the beneficiary's condition and the beneficiary is completely incapable of 
standing up from a regular armchair or any other chair at home. Medicare guidance says a recliner chair is not 
reimbursed separately from a seat lift. The item at issue in this appeal does not serve a purpose that is primarily 
medical in nature. This item is available to the general public and would be helpful even to those who are not 
sick or injured. Therefore, we decided that the Plan does not have to pre-approve a recliner and seat lift 
mechanism.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital bed, total electric (head, foot and height 
adjustments), with any type side rails, with mattress (CPT Code E0265). 
 
You asked the Plan to pre-approve the total electric bed. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health 
Plan. 
 
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 total electric bed have not been met. The rules say that a total 
electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a 
convenience feature. Total electric beds will be denied as not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pre-approve hospital bed, total electric (head, foot and height adjustments), with 
any type side rails, with mattress (CPT Code E0265).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast reconstruction surgery following implant 
removal. 
 
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. 
The Plan denied your request. The Plan says they will not preauthorize coverage of cosmetic breast 
reconstruction. The Plan states you had removal of cosmetic breast implants. The Plan states the outcome of 
procedure was discussed with you and you were aware at the time of surgery, cosmetic reconstruction was not 
covered. 
 
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 services have not been met. You do not meet any of the clinic 
criteria for breast reconstruction. Displeasure with outcome of removal of cosmetic breast implants is not an 
indication for coverage of reconstructive breast surgery Therefore, we decided that the Plan does not have to 
pre-approve breast reconstruction surgery following implant removal.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
physician. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that 
the Plan does not cover out-of-network services except when it is emergency care or urgently needed services, 
or if Medicare requires the plan to cover the services and providers in the network cannot provide needed care 
(prior authorization is needed). 
 
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 services 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 
physician's services to be provided by the requested physician.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 27, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says with 
limited exceptions, the members must use network providers to get their medical care and services. The only 
exceptions are emergencies, urgently needed services when the network is not available (generally, when the 
member is out of the area), out of area dialysis services, and cases in which the Plan authorizes use of out-of-
network providers. 
 
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 did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on July 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
March 15, 2020, through March 21, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $350 copayment each day, for days 1-5 and a $0 copayment for days 6 and beyond, for inpatient 
hospital care. Cost sharing is charged for each inpatient stay.  
 
The enrollee has been asked to pay $1,750 ($350 copayment x 5 days) for the inpatient hospital care provided. 
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 upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from  
March 15, 2020, through March 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating 
provider on July 1, 2020. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you do not think you should have to pay 
for this x-ray. 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 $40 
copayment for outpatient diagnostic tests/basic imaging service.  
 
You have been asked to pay a $40 copayment for an x-ray. Since an x-ray was provided, the correct copayment 
has been applied. An x-ray falls within the outpatient diagnostic tests/basic imaging service 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 by a participating provider on July 1, 
2020.