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

 
We decided that the Plan does not have to pay for x-ray services provided on February 17, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the out of network x-ray services. You say that the services in dispute do not 
require authorization. The Plan denied your request. The Plan says pre-certification and authorization was 
absent. 
 
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 x-ray services provided on February 17, 2020 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 17, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on February 17, 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 services are necessary. The Plan 
denied your request. The Plan says the care required can be provided in the current inpatient hospital 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence that the enrollee requires services that are not currently available.  
As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care needs. 
 
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation treatment (77522).
You asked the Plan to pre-approve proton beam radiation treatment. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. 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 proton beam radiation treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than intensity-modulated radiation therapy/image-guided radiation therapy (IMRT/IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to enrollees. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation treatment (77522).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided by a 
participating provider on February 17, 2020. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you do not agree with 
this copayment. 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 $35 
copayment for urgently needed services.  
 
You have been asked to pay a $35 copayment for urgently needed services. The correct copayment has been 
applied to the services that were provided. Urgently needed services 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 urgently needed services 
provided by a participating provider on February 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625).
You asked the Plan to pre-approve radiofrequency ablation. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been established.
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 radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the use of radiofrequency ablation for pain management related to sacroiliitis has not been shown to provide a clear long-term benefit over standard treatment for chronic sacroiliac joint pain. Based upon review of the medical literature, radiofrequency ablation used for sacroiliac joint pain is considered investigational and not medically 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq and Avastin. 
 
You asked the Plan to pre-approve the chemo regimen. You say that you would like reconsideration because 
this combination is medically necessary. The Plan denied your request. The Plan says there is no support found 
in the Medicare compendia for the use of Avastin as monotherapy without Tecentriq. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the chemo regimen. Our reviewer says 
that Tecentriq and Avastin not supported by major drug compendia or the CMS approved medical literature. 
Our physician reviewer found this combination is not a standard therapy after prior therapy. The service is not 
reasonable or medically 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 chemo regimen have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Tecentriq and Avastin.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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. Our 
physician reviewer found 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 or to require regular physician 
evaluation. Your care needs can be met at a lower level of 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 waive the copayments for the wound care provided from December 2, 2019 to December 16, 2019.
You asked the Plan to waive the copayments for the wound care. You say that you were instructed to go to this facility and these charges should not be billed to you. You say you cannot afford this copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $50 copayment for each visit for Medicare-covered outpatient hospital services. The enrollee has been asked to pay a $50 copayment for the wound care on each date of service. ($50 x 3 visits = $150). The wound care falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. 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 copayments for the wound care provided from December 2, 2019 to December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 5, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for this copayment because it was directly related to your surgery in November 2019. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $45 copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health professionals in a specialist's office. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.
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 specialist office visit provided on March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hand brakes and a basket for a walker. 
 
You asked the Plan to pre-approve hand brakes and a basket for a walker. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that hand brakes and baskets for walkers are non-
covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hand brakes and a basket for a walker have not been met. Therefore, we decided that the Plan does 
not have to pre-approve hand brakes and a basket for a walker.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from January 11, 2020 to January 13, 2020.
You asked the Plan to pay for the self-administered drugs. You say that no drugs that the enrollee received were self-administered. You also say that all of the drugs should be covered by the Plan. The Plan denied your request. The Plan says self-administered drugs are not covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from January 11, 2020 to January 13, 2020.
Benefits for the self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve a stair lift. You say that you have very limited mobility. The Plan denied 
your request. The Plan says home modifications and associated fees are excluded. 
 
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 stair lift.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Advair Diskus for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee is stable and doing well on this 
medication. The Plan denied your request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Advair Diskus for the 
enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you believe the patient meets Medicare criteria for 
Acute Inpatient Rehab and will benefit from Acute Inpatient Rehab that cannot be accomplished from a lower 
level of care. The Plan denied your request. The Plan says based on Medicare guidelines and the information 
about the enrollee's condition, the enrollee does not meet the requirements. 
 
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. Our 
physician reviewer found that the records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a SNF level of care.  Ongoing pain medication and other medication 
management, wound/skin care, and daily therapy can be provided at a SNF. The enrollee is mostly 
MODERATE to MAX assist for functional transfers, activities of daily living and a less intensive, longer 
duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An 
IRF intensity is not warranted. 
 
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 IRF admission and services.
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 you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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. Our 
physician reviewer found the enrollee required minimal assistance for bed mobility. The enrollee required 
moderate assistance of two for transfers and walking 15 feet with a rolling walker. The enrollee is on home 
oxygen. The documentation does not support that the enrollee would be expected to participate in or benefit 
from an intensive rehabilitation therapy program. The documentation does not support that the enrollee requires 
an interdisciplinary approach to rehabilitation care. The enrollee's care needs can be met at a lower level of 
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: 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 therapy needs can now be met at a lower level of care in the subacute nursing facility.
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. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. It is not clear you would be able to fully benefit and/or participate in an IRF 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation supporting the medical necessity for a step therapy exception. 
 
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 injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not 
tried and failed Orthovisc and Monovisc. There is no documentationprovided indicating that the plan's required 
drugs would likely be less effective and/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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Synvisc injection for the enrollee.