Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the enrollee has tried and failed physical therapy and
conservative management. The Plan denied your request. The Plan says the enrollee has not tried Synvisc,
Durolane, and Gelsyn-3.
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 physician reviewer found
that the enrollee has pain related to osteoarthritis of the right knee, diagnosis confirmed with imaging studies.
She has failed conservative treatment. The Plan requires a trial of drugs Synvisc, Durolane, and Gelsyn-3
before they will approve the requested drug. The enrollee has not tried and failed the required drugs. There is
no indication that the plan's required drugs would likely be less effective, or 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparotomy (47015) provided on July 12, 2019.
You asked the Plan to pay for the laparotomy. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says certified surgical technicians are not
recognized for payment.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the laparotomy (47015) provided on
July 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard.
You asked the Plan to pre-approve the occlusal guard. You say that the enrollee suffers from
temporomandibular joint (TMJ), and her jaw occasionally locks. The Plan denied your request. The Plan says
this service is not covered under the enrollee's benefit plan.
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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an
occlusal guard.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp.
You asked the Plan to pre-approve the ramp. You say that you are not mobile, and you need help with steps.
The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve a wheelchair ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature for the power wheelchair.
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says the requested item is non-covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature for the power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July
6, 2020, to July 10, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says there is a DRG procedure code error.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We find that the denied services are not supported in the medical record. Specifically, the DRG used -
0JH70MZ Insertion of Stim Geninto Back Subcutaneous/Fascia, Open Approach - is not a covered procedure.
Based on this information, we decided that Medicare rules for coverage of the services have not been met.
Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee
from July 6, 2020, to July 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on May 5, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 G0483 is drug test(s), definitive, utilizing (1) drug
identification methods able to identify individual drugs and distinguish between structural isomers (but not
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type,
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g.,
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drugspecific
calibration and matrix-matched quality control material (e.g., to control for instrument variations and
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or
more drug class(es), including metabolite(s) if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not
include definitive laboratory results for 22 or more drug classes to support this code. Based on this information,
we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that
the Plan does not have to pay for the drug testing coded G0483 provided on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on July 15,
2020.
You asked the Plan to waive the copayment for urgent care visit. You say that your understanding is that there
is to be no copayment for COVID-19 testing. The Plan denied your request. The Plan says the copayment
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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $35
copayment for urgent care visit. This copayment was applied to an urgent care office visit, not to COVID-19
testing.
You have been asked to pay $35 copayment for urgent care visit. Urgent care visit falls within the Urgently
Needed Services benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an urgent care visit
provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first 15 minutes of deep sedation/general anesthesia
(D9222), two subsequent 15-minute increments of deep sedation/general anesthesia (D9223), consultation
(D9310), and therapeutic parenteral drugs (D9612) provided on August 25, 2020.
You asked the Plan to pay for the deep sedation/general anesthesia services, consultation, and therapeutic
parenteral drugs. You say that you understand that you saw an out-of-network dentist. You also say that the
services you received are covered with in-network and out-of-network providers. The Plan denied your request.
The Plan says these services are not covered benefits under your dental plan.
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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first
15 minutes of deep sedation/general anesthesia (D9222), two subsequent 15-minute increments of deep
sedation/general anesthesia (D9223), consultation (D9310), and therapeutic parenteral drugs (D9612) provided
on August 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opsumit, 10 mg tablet.
You asked the Plan to pre-approve Opsumit. You say that the enrollee has been on Opsumit since February
2020. You say that the enrollee has had good results. You also say that the enrollee is at high risk of significant
adverse clinical outcome with medication change at this time. The Plan denied your request. The Plan says the
requested drug is considered self-administered. The Plan says self-administered drugs are covered under a
Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare
Part B.
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 Opsumit, 10 mg tablet.
Benefits for Opsumit 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone pkt (J3490).
You asked the Plan to pre-approve Testosterone pkt (J3490). You say that you want the enrollee treated with
this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare
Part B benefit.
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 Testosterone pkt (J3490).
Benefits for Testosterone pkt (J3490) 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
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 cannot be approved.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental for use in spinal fusion surgery. 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve OON office visits. You say that these visits are medically necessary. The
Plan denied your request. The Plan says the care the enrollee needs is available in-network.
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 office visits to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Humira pen.
You asked the Plan to pre-approve the Humira pen. The Plan denied your request. The Plan says this drug is
intended for self-administration. The Plan also says that this drug is not covered under Part B.
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 the Humira pen.
Benefits for the Humira 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81406, 81408, 81432, 81479) provided on June 13, 2020.
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that , to report a CGP service, test providers should use CPT code 81479. We looked at the file and Medicare rules. The laboratory services at issue are considered CGP testing and should be billed with CPT 81479. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81406, 81408, 81432, 81479) provided on June 13, 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 ongoing skilled therapy and nursing needs can be provided at a lower 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a subdural hematoma after a fall. C1 fracture, facial fractures and rib fractures were managed conservatively. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 11, 2020, by an outof-
network provider.
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied
your request. The Plan says the services were not authorized by the Plan to be performed by an out-of-network
provider. The Plan states the services are not considered urgent/emergent in nature. 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 preapprove
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 medical services provided on
August 11, 2020, by an out-of-network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.
You asked the Plan to pre-approve Hyalgan. You say that the injections would work better for the enrollee's condition than the preferred products. The Plan denied your request. The Plan says there are no contraindications to Durolane, Gelsyn-3, and Synvisc.
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 Hyalgan. Our physician reviewer found that the enrollee has a diagnosis of bilateral osteoarthritis of the knee. The Plan requires a trial of Durolane, Gelsyn-3, and Synvisc before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective, or likely have adverse effects 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99233) provided on
March 2, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says this service denied as included in another service, this service was included in and paid
for under the original claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Based on this information, we decided that Medicare rules for coverage of the services have not been met.
Codes billed were 99239, which was paid, and for discharge, the corrected claim showed the 99233 code for
subsequent care per day. Only one of this service can be paid per day when services are for providers of the
same specialty and diagnosis, which was the case for these claims. Therefore, we decided that the Plan does not
have to pay for subsequent hospital care (CPT Code 99233) provided on March 2, 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. The Plan denied your request. The Plan says your
medical needs are being met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician
reviewer found that you were admitted to the acute hospital for the treatment of acute respiratory failure due to
COVID infection. You are receiving appropriate care at the present acute care hospital. You do not require
services at the LTACH that are not available at the acute care hospital where you are currently receiving care.
There are no services available at the LTACH 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
your diagnosis and condition.
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.