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

We decided that the Plan has to pre-approve a cervical epidural steroid injection (CESI) for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has chronic neck pain that radiates to her arms. There is decreased range of motion in the neck and positive Hoffman reflexes on physical exam. The magnetic resonance imaging (MRI) shows cervical spondylosis at multiple levels as well as multi-level disc protrusions. She also has foraminal stenosis at multiple levels. She had prior epidural steroid injections and facet joint injections with significant pain improvement. The requested CESI is reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a cervical epidural steroid injection (CESI) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 3, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis
provided on September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vectra DA testing provided on August 19, 2019 by an out of network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that prior authorization is needed for genetic testing from both in- and out-of-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. 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 Vectra DA testing provided on August 19, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent Injection 75 mg/ml.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says this medication is covered under Part D benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Praluent Injection 75
mg/ml.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on December 29, 2018.
You asked the Plan to pay for the ambulance services. You say that the transport was medically necessary. The Plan denied your request. The Plan says you did not request prior authorization.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. Prior authorization for the non-emergency transport was not requested. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services provided on December 29, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on June 4, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that laboratory services were not rendered on this date of service. 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 $40 copayment for labs. The medical records show that you received laboratory services on June 4, 2019. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for laboratory services. Laboratory services fall 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 laboratory services provided on June 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis provided on August 29, 2019,
August 31, 2019, September 2, 2019 and September 3, 2019.
You asked the Plan to waive the coinsurance for dialysis. You say that your dialysis should have been covered
in full. The Plan denied your request. The Plan says the coinsurance 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 20%
coinsurance for renal dialysis services at an in-network dialysis center.
You have been asked to pay a total of $286 for dialysis.

Date of Service: August 29, 2019 
Service: Dialysis 
Allowed Amount: $355 
Coinsurance: 20% 
Member Liability: $71

Date of Service: August 31, 2019 
Service: Dialysis 
Allowed Amount: $355 
Coinsurance: 20% 
Member Liability: $71

Date of Service: September 2, 2019 
Service: Dialysis 
Allowed Amount: $360 
Coinsurance: 20% 
Member Liability: $72

Date of Service: September 3, 2019 
Service: Dialysis 
Allowed Amount: $360 
Coinsurance: 20% 
Member Liability: $72

TOTAL Member Liability: $286

Dialysis falls within the "Services to treat kidney disease" 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 dialysis provided on August 29, 2019, August 31, 2019, September 2, 2019 and
September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine you received on October 2, 2019.
You asked the Plan to pay for the vaccine. You say that you were past due for the vaccine. The Plan denied your request. The Plan says this is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine you received on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture and infrared therapy services provided on December 20, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these are not covered services.
The Plan must follow Medicare rules. The rules say that acupuncture services and infrared therapy services are not covered by Medicare. The services at issue in this appeal are acupuncture services and infrared therapy services. Therefore, we decided that the Plan does not have to pay for the acupuncture and infrared therapy services provided on December 20, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic imaging provided on August 6, 2019 by an out of
network provider.
You asked the Plan to pay for diagnostic imaging. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for
these 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 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 diagnostic imaging provided on August 6, 2019 by
an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on June 24, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that the claim says you should not be billed. You say that you are not responsible. 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 $5 copayment for in-network, outpatient lab services. You have been asked to pay a $5 copayment for laboratory services. The laboratory services fall 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 laboratory services provided on June 24, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).
You asked the Plan to pre-approve the Synvisc-One. You say that the Synvisc-One is medically necessary. The Plan denied your request. The Plan says the member has not met step-therapy exception criteria.
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 Synvisc-One. Our reviewer says that the documentation does not indicate that the member has tried and failed a trial on Monovisc. Our physician reviewer found it is not documented that Monovisc would likely be less effective or would likely have adverse effects.
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 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 rendered on September 5, 2018.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are
statutorily excluded.
The provider submitted a claim for procedure codes 85025, 80053, and 82803. These services were billed
under the Physician Fee Schedule and have a status indicator of X. These codes are statutorily excluded from
payment under the Physician Fee Schedule. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on September 5, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from March 28, 2019 to April 2, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that the charges are too high. 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 $295 copayment per day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from March 28, 2019 to April 2, 2019. Therefore, you are responsible to pay a $295 copayment for days 1-5 (March 28, 2019 to April 1, 2019). $295 (copayment) x 5 (inpatient days) = $1,475.00. You have been asked to pay the total copayment amount of $1,475.00 for an inpatient hospital stay. An 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 an inpatient hospital stay provided from March 28, 2019 to April 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) knee orthosis (L1851)
suspension sleeve (L2397) on July 31, 2019.
You asked the Plan to pay for the orthosis. You say that the medical records provided support the necessity of
the services in dispute. The Plan denied your request. The Plan says the records submitted did not include
documentation to support that the replacement of these braces was necessary due to loss or irreparable damage.
The Plan must follow Medicare rules. Medicare rules say that replacement refers to the provision of an
identical or nearly identical item. Equipment which the beneficiary owns or is a capped rental item may be
replaced in cases of loss or irreparable damage. The enrollee had received orthosis coded as L0650 from a
different provider on October 9, 2017. This is prior to the 5 years which Medicare determines is the reasonable
useful lifetime for the equipment. The enrollee also received the orthosis coded as L1851 and L2397 from a
different provider on March 14, 2018. This is prior to the 3 years that LCD determines is the reasonable useful
lifetime for the equipment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the
lumbar-sacral orthosis (L0650) knee orthosis (L1851) suspension sleeve (L2397) on July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an out-of-network weight loss program provided on April 22,
2019.
You asked the Plan to pay for an out-of-network weight loss program. You say that you sought this service as
an alternative to surgery. The Plan denied your request. The Plan says weight loss services are covered only in
a primary care setting with in-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 Plan contract also says that therapy to promote sustained
weight loss is covered if you get it in a primary care setting.
The requested provider in this case is not part of your primary care setting, nor is it a network provider with the
Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan
did not pre-approve the 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 an out-of-network weight loss
program provided on April 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for mammography services (77065) provided on July 22, 2019
by an out of network provider.
You asked the Plan to pay for the mammogram. You say that the services were medically necessary. The Plan
denied your request. The Plan says the services were not emergent or pre-authorized. The plan has in-network
providers than can provide the services at issue.
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 mammography services (77065) provided on July
22, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee scooter
You asked the Plan to pre-approve the knee scooter. You say that the enrollee is scheduled to have foot and
ankle surgery and will be non-weight bearing. The Plan denied your request. The Plan says the medical records
do no establish criteria that specifically support the use of a knee scooter. Alternative options are crutches or
wheelchair.
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 knee scooter. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the medical records do not support the use of a knee scooter over other forms of non-weight
bearing equipment for ambulation in the home. Alternative options are crutches or wheelchair. More
documentation is needed.
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 knee scooter have not been met. Therefore, we decided that the Plan does
not have to pre-approve the knee scooter.
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 meets Medicare criteria for
LTACH services.
The Plan denied your request. The Plan says the record does not show that the enrollee will require further
acute hospital care for more than 25 days.
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 based on the provided medical records the acute care hospital is able to provide all of
the services the patient requires. Continued care at this level is appropriate until the patient is stable to transfer
to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility or sub-acute
rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care.
You asked the Plan to pre-approve inpatient psychiatric care. You say that the enrollee needs medication
administration and constant mood assessment and is unsafe to go home. The Plan denied your request. The
Plan says the enrollee could be treated at an alternate level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient psychiatric care. Our reviewer
says that it is not medically reasonable and necessary at this time to have psychiatric care provided at the acute
inpatient level of care rather than a lower level of care. Our physician reviewer found the records show that it is
not expected this enrollee will improve in a reasonable period of time as she does not have dangerousness to
self or others, auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment
while not showing any aggressive behaviors.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient psychiatric care.