Persius/hicric huggingface dataset:
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 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 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 review has determined that the enrollee does not require services at the LTACH 
that are not available at the acute care hospital where they are 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 long-term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Metronidazole Topical Gel for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this 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 Metronidazole Topical Gel 
for the enrollee.  
 
Benefits for this drug 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: SNF
Decision: Favorable

 
We decided that the Plan has to pay for continued SNF services from March 20, 2020, to March 23, 2020. 
 
You asked the Plan to pay for SNF care. You say that a provider told you that you could not go home until 
March 23, because you had a pneumonia. You also say that you were unaware coverage would end on March 
19, 2020. The Plan denied your request. The Plan says that custodial care is excluded from coverage. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before March 19, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pay for continued SNF services from March 20, 2020, to March 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you need this because you cannot walk long 
distances. The Plan denied your request. The Plan says a walker is more appropriate for you in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that a power mobility device is covered only if the 
beneficiary?s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted 
cane or walker.  
 
We looked at the file and Medicare rules. The records indicate that your mobility limitation can be sufficiently 
and safely resolved by the use of an appropriately fitted walker. Based on this information, we decided that 
Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for diagnostic mammography, tomosynthesis, 
and ultrasound provided on June 29, 2020. 
 
You asked the Plan to waive the deductible for diagnostic imaging. You say that your annual mammogram was 
unclear so you were called back for second imaging, but no one mentioned a cost would be associated. The 
Plan denied your request. The Plan says the deductible amount you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible for diagnostic imaging. At the time these claims were 
processed, $0 of the $750 deductible had been met. The allowed amounts of these claims total $735.38, 
resulting in a deductible obligation of $735.38. 
 
The items or services you asked the Plan to waive the deductible for fall within the benefit category Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible for Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies. This cost sharing is a contractual obligation that had not been met at the time diagnostic 
imaging was received on June 29, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible for diagnostic mammography, tomosynthesis, and ultrasound provided on June 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that Zilretta has previously been very successful for the 
enrollee. The Plan denied your request. The Plan says Zilretta is not intended for repeat administration. 
 
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 Zilretta. Our reviewer says that Zilretta 
is not medically reasonable and necessary. Our physician reviewer found Zilretta is an experimental drug for 
knee pain. Our reviewer also found that 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One (J7325). 
 
You asked the Plan to pre-approve Synvisc-One. You say that Synvisc-One is medically necessary. The Plan 
denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives 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 Synvisc-One. Our reviewer says that 
Synvisc-One is not medically necessary. Our physician reviewer found the record shows no trial of the plan 
preferred drugs. There is no record of any reason the plan preferred drugs would be unsafe or ineffective 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One (J7325).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (99205, 36415) provided on February 
4, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you became a contracted provider effective 
February 1, 2020. The Plan denied your request. The Plan says you did not become a contracted provider until 
March 1, 2020. Thus, prior authorization was not obtained by the facility or the provider; therefore, payment 
has been correctly denied. 
 
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 (99205, 36415) provided 
on February 4, 2020, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from June 19, 2019, to June 24, 2019. 
 
You asked the Plan to pay for inpatient care. You say that the diagnoses are exempt from POA reporting. The 
Plan denied your request. The Plan says exempt diagnoses must be billed with a POA indicator of 1. 
 
The Plan must follow Medicare rules. Medicare rules say that providers should submit a Present On Admission 
(POA) Indicator for every diagnosis on your inpatient acute care hospital claims. A POA Indicator of 1 is used 
to indicate the diagnosis is exempt from POA reporting. 
 
We looked at the file and Medicare rules. The services at issue were billed with diagnoses missing POA 
indicators. Based on this information, we decided that Medicare rules for coverage of inpatient care have not 
been met. Therefore, we decided that the Plan does not have to pay for inpatient care provided from June 19, 
2019, to June 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on June 1, 2020. 
 
You asked the Plan to pay for the dental service. You say that the Explanation of Benefits shows that you paid 
$68. You say that you did not pay for the service. You say that this seems suspicious. You also say that you are 
not satisfied with your dentist. The Plan denied your request. The Plan says panoramic x-rays are covered once 
every 3 plan years. The Plan also says the frequency limit has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and panoramic x-rays are a covered 
service, the frequency limit of 1 every 3 plan years has been exceeded. The record shows that the Plan paid for 
this service that you received on March 29, 2018. Therefore, we decided that the Plan does not have to pay for 
the panoramic x-ray (D0330) provided on June 1, 2020.  
 
Your complaint about your dentist is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not require any daily skilled nursing services, and 
does not require daily skilled therapy. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea standard manual wheelchair for the enrollee.You asked the Planto pre-approvethe wheelchair. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no documentation that the wheelchair is needed to accomplish MRADLs. 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 wheelchair. Our reviewer says that the requested wheelchair is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal treating medical practitioner notes that support that the enrollee has a personal mobility deficit that impairs participation in MRADLs in the home. The documentation does not reveal why the enrollee's mobility deficit is unable to be helped by a walker or a cane. There is no treating medical practitioner objective gait or neuromuscular exam. The documentation is not clear on a treating medical practitioner note that the enrollee has the ability to safely maneuver the wheelchair in the home. The documentation is not clear that the enrollee has a caregiver that is willing and able to propel the wheelchair.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 wheelchair have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea standard manual wheelchair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for therapeutic injections provided from 
March 11, 2020, to July 15, 2020. 
 
You asked the Plan to waive the coinsurance for therapeutic injections. You say that you were not charged for 
certain dates of service but were charged for others and disagree with the charges. The Plan denied your 
request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received therapeutic injections from March 11, 2020, to July 15, 2020 for a total of 4. The allowed amount 
per each therapeutic injection is $57.45 and 20% of that is $11.49. The total amount you owe is: $11.49 
(coinsurance) x 4 (therapeutic injections) = $45.96. 
 
You have been asked to pay the total coinsurance amount of $45.96 for therapeutic injections. Therapeutic 
injections fall within the Medicare Part B prescription drugs benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for therapeutic injections provided from March 11, 2020, to July 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 14 Day Reader. 
 
You asked the Plan to pre-approve the FreeStyle Libre 14 Day Reader. You say that you would like 
reconsideration because the requested supplies are medically necessary. The Plan denied your request. The 
Plan says medical necessity cannot be determined. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the FreeStyle Libre 14 Day Reader have not been met. Specifically, there is insufficient 
information to determine whether the member meets LCD criteria for this equipment. Without sufficient 
documentation, we cannot confir that Medicare coverage criteria have been met. Therefore, we decided that the 
Plan does not have to pre-approve FreeStyle Libre 14 Day Reader.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is 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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is 
with spinal stenosis. The requested Vertiflex device is experimental. More research is needed. It is not 
medically reasonable or 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this enrollee is medically stable, and will 
benefit from a transfer to a LTACH. The Plan denied your request. The Plan says the LTACH services you are 
requesting do not meet the requirements for approval. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. Our reviewer found that 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. Our physician reviewer also found that 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the posterior tibial neurostimulation (64566) provided on 
February 11, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for posterior tibial neurostimulation. You say that the service rendered were 
medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-
emergent services rendered by an out-of-network provider. 
 
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 posterior tibial neurostimulation (64566) 
provided on February 11, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home infusion therapy services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has difficulty being 
transported to the wound center. The Plan denied your request. The Plan says the services are not valid for 
Medical purposes 
 
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 the services are not covered when billed with the requested CPT codes S5502, S9500, and 99601.  
Specifically, Medicare uses another code for the reporting of, and payment for, these services. Based on this 
information, we decided that Medicare rules for coverage of the requested services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve home infusion therapy services.