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

We decided that the Plan does not have to pre-approve Zarxio, Cisplatin, Docetaxel, Ondansetron IV and
Dexamethasone.
You asked the Plan to pre-approve the Zarxio, Cisplatin, Docetaxel, Ondansetron IV and Dexamethasone. You
say that you would like reconsideration as these drugs are medically necessary. The Plan denied your request.
The Plan says the member does not meet step therapy exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the Zarxio, Cisplatin, Docetaxel,
Ondansetron IV and Dexamethasone. Our reviewer says that the member has not tried the other formulations of
peg-filgastrim approved by the Plan. Our physician reviewer found the preferred drugs are likely to be as
effective as the requested drugs.
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 Zarxio, Cisplatin, Docetaxel, Ondansetron IV and Dexamethasone have not
been met. Therefore, we decided that the Plan does not have to pre-approve Zarxio, Cisplatin, Docetaxel,
Ondansetron IV and Dexamethasone.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional resin-based composites of two surfaces
each provided on February 27, 2020.
You asked the Plan to pay for the additional resin-based composites of two surfaces each. You say that you are
on a set income and did not realize that you could only have 2 fillings per year. The Plan denied your request.
The Plan says the benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, restorations are limited to two
procedures per calendar year. The record shows that you received 4 resin-based composites (D2331 x3 and
D2332 x1) on February 27, 2020, the Plan paid for two resin-based composites (D2331 x1 and D2332 x1) and
your restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the
two additional resin-based composites of two surfaces each provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit provided on March 2, 2020.
You asked the Plan to waive the copayment for the office visit. You say that this doctor is not your internist.
You say that the copayment was charged in error. The Plan denied your request. The Plan says that the
copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay a $0 copayment for each primary care physician visit for a
Medicare-covered service.
The Plan says you must pay a $45 copayment for the office visit. Based on the Plan contract, however, you
cannot be asked to pay more than a $0 copayment for the office visit. The records show that you were seen at
an internal medicine office by an internal medicine provider, which is considered a primary care physician.
Therefore, we decided that the Plan has to waive the copayment for the office visit provided on March 2, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit and ultrasounds
provided on January 22, 2020.
You asked the Plan to waive the copayments for the specialist office visit and the ultrasounds. You say that
your in-network doctor in his office. You say the insurance did not pay for the office visit and your copayment
is $229.27. 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 $20
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse
practitioner or physician's assistant or other non-physician health care professionals in a specialist's office and a
$155 copayment for each Medicare-covered radiological diagnostic services, not including x-rays, performed
in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a total of $229.27 for the specialist office visit and the ultrasounds. The specialist
office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category.
The ultrasounds fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit
category. See chart below. 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 copayments for the specialist office visit and the ultrasounds provided on January 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the knee replacement provided from January 17, 2020 through January 24, 2020.
You asked the Plan to waive the coinsurance for the knee replacement. You say that this required an overnight hospital stay. You say that this shouldn't have been billed as outpatient. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for surgery performed at an outpatient hospital facility. You have been asked to pay $2,423.27, which is 20% of the allowed amount for the knee replacement. The allowed amount is $12,116.37 (20% x $12,116.37 = 2,423.27). The knee replacement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the knee replacement was billed as an outpatient procedure from January 23, 2020 through January 24, 2020.
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 knee replacement provided from January 17, 2020 through January 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for gait training (97116) provided on July 10, 2019.
You asked the Plan to pay for gait training. You say that you did walking training on your own at the end of
your session. The Plan denied your request. The Plan says this service is not documented in the record.
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 97116 is therapeutic procedure, 1 or more areas, each 15
minutes; gait training (includes stair climbing).
We find that CPT code 97116 is not supported in the medical record. Specifically, gait training is not
documented in the submitted medical records as having been performed by the physician. Based on this
information, we decided that Medicare rules for coverage of gait training have not been met. Therefore, we
decided that the Plan does not have to pay for gait training (97116) provided on July 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for BLS non-emergency ambulance transport (A0428, GY) and ground mileage (A0425, GY) provided November 6, 2019.
You asked the Plan to pay for the ambulance transport. You say that you were being discharged from the hospital and the hospital staff would not let you be transported by family and said you had to go by ambulance. The Plan denied your request. The Plan says by adding the GY modifier, the ambulance company has indicated this trip is not payable. If the enrollee feels the GY modifier was used inappropriately, they would need to discuss this issue with the ambulance company.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Per Medicare guidelines the GY modifier is used to indicate that this is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of the ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for BLS non-emergency ambulance transport (A0428, GY) and ground mileage (A0425, GY) provided November 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxychloroquine for the enrollee.
You asked the Plan to pre-approve this drug. You say that without this medication the enrollee's condition
could worsen. 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 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 Hydroxychloroquine 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve the Euflexxa. You say that you would like reconsideration because you have
knee pain and other therapies have not worked. The Plan denied your request. The Plan says you do not meet
step therapy exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the Euflexxa. Our reviewer says that
you do not have a history of failure, contraindication, or intolerance to the formulary alternatives: Synvisc,
Durolane, and Gelsyn-3. Our physician reviewer found the documentation does not outline contraindications or
reasons these medications were not 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 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 waive the coinsurance for the clinic visit provided on February 4, 2020.
You asked the Plan to waive the coinsurance for the clinic visit. You say that this was a preventive eye care
visit. You say that the cost should be $0. The Plan denied your request. The Plan says the coinsurance applied
correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of
the cost for each outpatient hospital visit. Covered services include services in an emergency department or
outpatient clinic.
You have been asked to pay $28.93, which is 20% of the allowed amount for the clinic visit. The allowed
amount is $144.66 (20% x $144.66 = $28.93). The clinic visit falls within the "Outpatient hospital services"
benefit category. The records show that an outpatient clinic visit was billed. 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 clinic visit provided on February 4, 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 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 were medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. Functionally, given your current functional status, you do not need IRF admission and you cannot tolerate it either. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status and medical stability. 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 reimburse you for the stair lift provided on September 30, 2019.
You asked the Plan to reimburse you for the stair lift. You say that you need a stair lift to get upstairs to your
living quarters. The Plan denied your request. The Plan says stair lifts are not covered by Medicare or the Plan.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to reimburse you for the stair lift provided on September 30,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for digital analysis of an EEG (95957) provided on December 3, 2019.
You asked the Plan to pay for the digital analysis of an EEG. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the digital analysis of an EEG. Our reviewer says that CPT code 95957 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of a Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) being performed on December 3, 2019, therefore this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the digital analysis of an EEG have not been met. Therefore, we decided that the Plan does not have to pay for digital analysis of an EEG (95957) provided on December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0800), battery and battery charger.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a POV is covered if the beneficiary's weight is less than or equal to the weight capacity of the POV that is provided. We looked at the file and Medicare rules. The file indicates your weight is not below the maximum capacity for this type of power mobility device. 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 pre-approve a power scooter (K0800), battery and battery charger.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF
admission.
The Plan must follow Medicare rules. The rules say that an 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 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's
current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may
benefit from additional multiple therapies; however, the enrollee's functional level does not require or indicate
that this therapy must be provided in an IRF with an intensive level 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 an acute inpatient rehabilitation facility (IRF) admission and services.
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 the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says the enrollee is medically stable with no further skilled needs.
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 the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or
therapy services on a daily basis. You do 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 the admission 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on
October 16, 2019.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were under the
impression that everything would be covered under the free dental cleaning that you are entitled to under your
plan. The Plan denied your request. The Plan says this service is not covered by the 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
complete series of intraoral x-rays (D0210) provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on February 4,
2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you had the same procedure last
year and were charged less. You say that you want to know why you owe this amount instead of 20%. The Plan
denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $145
copayment for each Medicare-covered radiological diagnostic service from an in-network provider.
You have been asked to pay $113.30, which is less than the standard $145 for the ultrasound. The ultrasound
falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the ultrasound provided on February 4, 2020.