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

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria have not been met. 
 
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 Euflexxa. Our reviewer says that the 
criteria for coverage of Euflexxa have not been met. Our physician reviewer found the Plan requires a trial of 
Orthovisc and Monovisc before they will approve the requested drug. Based on the medical records provided, 
the patient has not tried and failed the required drugs. There is no indication that the plan's required drugs 
would likely be less effective or have adverse effects 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to provide 5 additional physical therapy visits. 
 
You asked the Plan to provide 5 additional physical therapy visits. You say that physical therapy has improved 
the enrollee's ability to complete necessary ADLs. The Plan denied your request. The Plan says they will 
approve 5 physical therapy visits but an additional 5 is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
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 provide 5 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally 
accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy 
for this condition and it does not appear that the enrollee requires the unique skills of a professional therapist to 
safely and effectively provide treatment, or that the services can be safely and effectively performed only by a 
therapist, or under the supervision of a therapist. The enrollee has been authorized additional sessions to review 
an independent exercise program. The enrollee should follow up with the physician for persistent weakness 
which does not have a clear etiology from the documentation submitted. The  specialized skill, knowledge and 
judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the 
enrollee's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to provide 5 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on May 1, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on May 1, 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 your needs may be met at a different level of care. 
 
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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to 
perform fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs 
can be met at a lower level of care. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF services provided from April 1, 
2020, to April 9, 2020. 
 
You asked the Plan to waive the copayment for the SNF services. You say that you should not be responsible 
for the copay because you were not told there would be a high charge. The Plan denied your request. The Plan 
says the copayment amount that you are being charged is correct. 
 
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 day for days 1 to 20 and a $100 copayment per day for days 21 to 100 for Skilled Nursing 
Facility (SNF) care. This SNF stay previously had 15 days applied to it in March 2020. This portion of the SNF 
stay lasted 8 days, which are days 16 to 23 of the stay, resulting in a copayment amount of $400. 
 
You have been asked to pay a $20 copayment per day for days 1 to 20 and a $100 copayment per day for days 
21 to 100 for the SNF services. The SNF services fall within the Skilled Nursing Facility (SNF) care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the SNF services provided from April 1, 2020, 
to April 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Gammagard rendered on January 13, 
2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you were not aware that you didn't 
have 100 percent coverage. The Plan denied your request. The Plan says the coinsurance was 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 20% 
coinsurance for each Medicare-covered Part B drug.  
 
Review of the file shows that you received Gammagard on January 13, 2020. You have been asked to pay a 
20% coinsurance for these services, for a total of $944.16. These services fall within the Medicare-covered Part 
B drug 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 the Gammagard rendered on 
January 13, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient test provided by a 
participating provider on July 21, 2020. 
 
You asked the Plan to waive the copayment for radiological diagnostic service. You say that your copayment 
should only be $25. 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 $150 
copayment for outpatient diagnostic tests/radiological tests.  
 
You have been asked to pay a $150 copayment for radiological diagnostic service. Radiological diagnostic 
service falls within the outpatient diagnostic tests/radiological tests 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 outpatient test provided by a participating provider on July 21, 2020.
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 long-term acute care is medically 
necessary. The Plan denied your request. The Plan says there is no documentation that the enrollee would 
benefit from and improve with LTACH management. 
 
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 was admitted to the current acute care hospital with COVID-19. He had 
hypotension which improved with IV fluids. He was diagnosed with metabolic encephalopathy and hypoxia 
and was treated with oxygen, Remdesivir, dexamethasone, D5, Depakote, and Lopressor. He is requiring NG 
tube feeds. The enrollee's overall prognosis is poor, according to the notes. The enrollee appears to be more 
stable, however, he requires additional short-term acute care services which can take place safely at the current 
facility. The patient does not require services at the LTACH that are not already available at the current facility. 
There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Therefore, this request for LTACH will be considered not medically necessary at this time. 
When treatment has completed and the enrollee is more stable, transfer to a lower level of care may be 
considered. 
 
 
 
 
 
 
 
 
 
 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 23, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. 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 the medical services provided to the enrollee by an out-of-network provider 
on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on May 15, 2020.
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 procedure code 99152 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes. We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the patient's level of consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for t (CPT 99203) provided on February 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for t (CPT 99203) provided on February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says as the enrollee does not qualify for the wheelchair bases, none of the requested 
accessories can be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 medically reasonable or necessary. Our physician reviewer found there is no 
documentation that the enrollee needs the various power options and accessories, as there is no qualifying 
diagnosis for a group 3 power 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 Plan does not 
have to pre-approve a group 3 power wheelchair for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee tested positive for 
SARS-CoV-2 and was living in an assisted living facility. From a nursing perspective, the enrollee received 
oral medications.  The enrollee had stable vital signs.  His appetite was diminished.  He had some coughing and 
shortness of breath. Regarding rehabilitation services, the enrollee was ambulatory. 
 
 
 
There are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmology service provided on 
August 4, 2020. 
 
You asked the Plan to waive the copayment for the ophthalmology service. You say that the coinsurance is 
incorrect. The Plan denied your request. The Plan says you were charged the 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 $30 
copayment for Vision Care, specialist's office.  
 
The visual field examination was covered with no copayment. You have been asked to pay a $30 copayment 
for the ophthalmology service. The ophthalmology service falls within the Vision Care benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the ophthalmology service provided on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair with a seat lift mechanism. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. 
The Plan says this is considered a convenience item, and is not considered durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 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 pre-approve the services. Our reviewer says that the requested services are 
not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no 
documentation that you have severe arthritis of the hip or a neuromuscular disease. There is no documentation that the 
requested seat lift is included in the treating practitioner's course of treatment. There is no documentation that the seat lift 
is likely to effect improvement in your condition, or arrest or retard deterioration in your condition. There is no 
documentation that you are completely incapable of standing from a chair in the home. 
 
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
recliner chair with a seat lift mechanism.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography services coded 74178 provided on 
July 17, 2020. 
 
You asked the Plan to pay for the computed tomography services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 74178 is computed tomography, abdomen and pelvis; 
without contrast material in one or both body regions, followed by contrast material(s) and further sections in 
one or both body regions. 
 
We find that CPT code 74178 is not supported in the medical record. Specifically, this service was billed with 
diagnosis code C61 (Malignant neoplasm of prostate). This diagnosis code is not typically performed for an 
enrollee whose gender is female. Even if the service was appropriately billed, the appropriate modifier was not 
billed with this code to support the enrollee's gender being transgender, ambiguous genitalia, or hermaphrodite. 
Based on this information, we decided that Medicare rules for coverage of the computed tomography services 
have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography 
services coded 74178 provided on July 17, 2020.