Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Xolair injections (J2357) received from 
May 6 to July 1, 2020. 
 
You asked the Plan to waive the coinsurance for Xolair injections. You say that you cannot get the amount of 
money to pay the coinsurance. The Plan denied your request. The Plan says the correct coinsurance was 
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 20% 
coinsurance for Medicare-covered Part B drugs dispensed at a retail pharmacy, mail order pharmacy, physician 
office, and outpatient facility.  
 
You have been asked to pay $421.56, or 20% of the Plan-allowed amount of $2,107.80, for each one of 5 
Xolair injections. Xolair 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 Xolair injections (J2357) received from May 6 to July 1, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
radiofrequency ablation for pain management related to sacroiliitis has not been shown to provide clear long-
term benefits over the standard treatment for sacroiliac joint pain. 
 
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 requested services. Our physician 
reviewer found that you have chronic low back and hip pain. You underwent a diagnostic sacroiliac (SI) joint 
injection and had excellent relief. Radiofrequency ablation of the SI joint innervation is considered 
experimental/investigational due to the wide variation in efficacy reported in the peer reviewed literature.  
Therefore, the request is considered not medically reasonable or necessary. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from April 9, 2019, to 
May 9, 2019. 
 
The enrollee asked the Plan to pay for the skilled nursing services. The enrollee says that Medicare incorrectly 
disenrolled them, and placed them into another company's Plan D program. The enrollee also says that she had 
30 days of nursing home coverage remaining. The Plan denied your request. The Plan says Skilled Nursing 
Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from November 14, 
2018, to March 2, 2019. The Plan has covered 100 days of SNF care. 
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when they have not 
been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing services provided from April 9, 2019, to May 9, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services 
provided from March 23, 2020, to April 22, 2020. 
 
You asked the Plan to waive the copayment for the SNF services. You say that this stay was only supposed to 
last 21 days, but the enrollee could not be discharged due to COVID-19. The Plan denied your request. The 
Plan says this copayment was correctly charged. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $0 copayment for days 0-20 and a $160 copayment per day for days 21-100 for skilled nursing 
facility services.  
 
Records show that the enrollee was in the SNF for 30 days.  In accordance with the Plan contract, the enrollee 
was assessed a $0 copayment for days 1-20.  For the remaining 10 days, the enrollee was charged a $160 
copayment per day, for a total of $1600. This copayment applies regardless of the reason for the length of the 
stay. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. 
This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services 
provided from March 23, 2020, to April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient therapy for twenty (20) office visits of 
acupuncture services. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says no more than 20 acupuncture treatments may be administered annually. 
 
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 physician reviewer 
found the patient in this case appears to have benefited from acupuncture in the past, however, recent flare-up 
of low back pain from recent surgery warrants full trial of other first line methods such as NSAIDs and 
physical therapy, which were not noted to have been exhausted for this recent change. Therefore, based on the 
provided documentation, this request for acupuncture will be considered not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve outpatient therapy for twenty (20) office visits of acupuncture services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve powered mobility device (PMD) repairs and accessories 
(batteries, seat and horn). 
 
You asked the Plan to pre-approve PMD repairs and accessories. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the clinical information shows that your 
PMD requested repairs are not indicated. The Plan says that based on the documentation provided, your home 
is not wheelchair or PMD accessible. 
 
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.  
 
The file shows that you cannot safely operate a PMD within your home; therefore, the PMD repairs and 
accessories are not covered at this time. This means that Medicare rules for coverage of PMD repairs and 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve powered 
mobility device (PMD) repairs and accessories (batteries, seat and horn).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Outpatient Surgery Lumbar Vertiflex Interspinous (CPT 
Codes: C1821, 22870, 22869). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer remains experimental. 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 Outpatient Surgery Lumbar Vertiflex Interspinous (CPT Codes: C1821, 22870, 22869).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination (X-Ray) of pelvis (72170), 
transport of X-Ray equipment (R0070) and set up of portable X-Ray equipment (Q0092) provided on June 4, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for X-Ray of pelvis, transport and set up of portable X-Ray equipment. You say that 
the services 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 radiologic examination (X-Ray) of pelvis 
(72170), transport of X-Ray equipment (R0070) and set up of portable X-Ray equipment (Q0092) provided on 
June 4, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and prolonged evaluation and management 
service (99205, 99358) provided on June 19, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit and prolonged evaluation and management service. You say that 
you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says 
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 office visit and prolonged evaluation and 
management service (99205, 99358) provided on June 19, 2020, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need wound care. The Plan denied your request. 
The Plan says you do not need close physician rehab supervision. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital with a large right lower extremity hematoma, treated 
surgically, with a wound vac applied. You remained stable. IV antibiotics were being continued for 2 weeks. 
Education and a home exercise program were part of discharge planning. The limited documentation does not 
support that the complexity of your nursing, medical and rehabilitation needs requires an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. The documentation is not sufficient to demonstrate that there is a reasonable expectation that 
you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in 
an IRF. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has active medical problems that require 
him to be seen by a rehab physician at least 3 times a week. The Plan denied your request. The Plan says the 
enrollee's care is no longer complex, and he does not need a team of providers. 
 
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 physician reviewer found 
that the enrollee presented to the acute care hospital with a fall and a cecal mass. He was treated in the hospital 
with an uncomplicated right hemicolectomy. He is weak and deconditioned and is working with physical and 
occupational therapy. He is walking 30 feet with a rolling walker with minimum assistance, and is minimum to 
moderate assist for transfers and activities of daily living. He is reported to be medically stable for discharge. 
The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and 
occupational therapy services, but he does not require an intensive inpatient rehabilitation therapy program. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Thermal Swim Spa. 
 
You asked the Plan to pre-approve the Thermal Swim Spa. You say that you would like reconsideration 
because this equipment is warranted and recommended by your healthcare providers. The Plan denied your 
request. The Plan says your request is not a covered benefit because this item is a comfort and convenience 
item. 
 
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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Thermal Swim Spa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the genicular nerve block (64640). 
 
You asked the Plan to pre-approve the genicular nerve block. You say that due to her age she is not a candidate 
for knee surgery, and as an alternative to surgery you proposed the genicular cooled radiofrequency ablation. 
The Plan denied your request. The Plan says this service is considered investigational and experimental. There 
is no proven benefit and therefore not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-
approve the genicular nerve block (64640).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan. 
 
You asked the Plan to pre-approve Hyaluronan. You say that the enrollee has already tried one of the plan's 
preferred drugs. The Plan denied your request. The Plan says the enrollee has not tried and failed Durolane or 
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 Hyaluronan. Our physician reviewer 
found that the enrollee has right knee osteoarthritis. He has tried NSAIDs, physical therapy, Synvisc injections, 
and platelet-rich plasma injections, without significant long-lasting improvement. The Plan requires a trial of 
Durolane or Gelsyn-3 before they will approve the requested drug. The provided records do not show that the 
enrollee had tried and failed the required drugs.   
 
 
Durolane or Gelsyn-3 would not likely to be less effective, or have more adverse effects compared to the 
requested Hyaluronan. Current literature suggests that all available hyaluronic acid-based injections are 
essentially equal in effectiveness and safety. Therefore, the requested drug is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyaluronan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyaluronan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lightweight wheelchair accessories (quick release axles, 
privacy flap, solid seat insert, posterior back cushion). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 the accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not have significant postural asymmetries to indicate the cushion. The 
documentation is inconsistent between the DME consulting evaluation and the contracted ATP evaluation. The 
DME consulting evaluation indicates the patient has intact sitting balance. There is no evidence of postural 
asymmetry needing a positioning cushion on this evaluation. The lightweight wheelchair accessories are not 
medically necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a 
malformed body member therefore are not medically necessary per Social Security Act, Section 1862 (a)1(A) 
and the 42 CFR ?411.15(k). 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lightweight wheelchair accessories (quick release axles, privacy flap, solid seat insert, 
posterior back cushion).
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 you can safely receive the services you need in other settings. 
 
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 coronary artery bypass 
grafting. Your medical problems are stable. There are no identified problems that need inpatient medical 
management. 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. The medical record supports a need for physical and occupational therapy but it does not support a 
need for an intensive rehabilitation therapy 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.