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

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy provided from March 23, 
2020, to April 1, 2020. 
 
You asked the Plan to waive the coinsurance for radiation therapy. You say that you feel that the charges are 
incorrect. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct 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 20% 
coinsurance for radiation therapy.  
 
You received radiation therapy on March 23, 2020. The allowed amount is $5,062.66 and 20% of that is 
$1,012.53.  
 
You received radiation therapy on March 25, 2020. The allowed amount is $1,656.83 and 20% of that is 
$331.37. 
 
You received radiation therapy on March 27, 2020. The allowed amount is $1,656.83 and 20% of that is 
$331.37. 
 
You received radiation therapy on April 1, 2020. The allowed amount is $1,656.83 and 20% of that is $331.37. 
 
The total amount you owe is: $2,006.64.  

You have been asked to pay the total coinsurance amount of $2,006.64 for radiation therapy. Radiation therapy 
falls within the outpatient hospital 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 coinsurance 
for radiation therapy provided from March 23, 2020, to April 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen injection for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no diagnosis of primary humoral immunodeficiency. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found Medicare rules state 
that intravenous immunoglobulin is covered if the patient has a diagnosis of primary immune deficiency 
disease. The enrollee in this case has a diagnosis of secondary immunodeficiency related to the Waldenstrom's 
macroglobulinemia. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Privigen injection for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on March 26, 2020. 
 
You asked the Plan to pay for the paramedic intercept services. You say that you did not call the paramedics 
and they treated you for a condition you we not having. The Plan denied your request. The Plan says this item 
is not a covered benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area.  
 
The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we 
decided that the Plan does not have to pay for the paramedic intercept services provided on March 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the knee brace, knee joint lock and carbon 
graphite lamination provided on June 12, 2020. 
 
You asked the Plan to waive the coinsurance for the knee brace, knee joint lock and carbon graphite 
lamination. You say that you were told that the copayment would be $240 and were never told the provider 
wasn't in-network. 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 30% 
coinsurance. for each Medicare-covered prosthetic device and related supplies from an in-network provider. 
 
You have been asked to pay a total of $452.75 for the knee brace, knee joint lock and carbon graphite.  
 
Service Allowed Amount Standard Coinsurance Member Liability 
Knee Brace $1,262.68 30% $378.80 
Knee Joint Lock $118.76 30% $35.63 
Carbon Graphite 
Lamination 
$127.72 30% $38.32 
TOTAL:   $452.75 

The knee brace, knee joint lock and carbon graphite lamination falls within the "Prosthetic devices and related 
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 coinsurance for the knee brace, knee joint 
lock and carbon graphite lamination provided on June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an oral appliance to treat sleep apnea. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says that the 
enrollee's sleep apnea score is not severe enough to warrant the approval of this device. 
 
The Plan follows Medicare rules. Medicare rules say that oral appliances for obstructive sleep apnea are only 
covered under certain medical indications.  
 
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 item. Our physician 
reviewer found that the enrollee has experienced snoring, witnessed apneas, excessive daytime sleepiness, and 
an Epworth score of 10. The sleep study on July 15, 20202, showed OSA, with an elevated RDI of 15.4.  This 
meets Medicare criteria, even though the AHI was normal. Therefore, a mandibular advancement device is 
considered reasonable and 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 requested item have been met. Therefore, we decided that the Plan has to 
pre-approve an oral appliance to treat sleep apnea.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GenVisc (J7320). 
 
You asked the Plan to pre-approve GenVisc. The Plan denied your request. The Plan says the documentation 
did not support 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 GenVisc. Our reviewer says that 
GenVisc is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee 
has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the 
Plan, requires these be trialed first. Our reviewer found that the documentation does not outline 
contraindications or reasons these medications were not considered. Without the support of the documentation, 
GenVisc is not approved, as step criteria have not been met. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GenVisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve GenVisc (J7320).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a drug-eluting implant (0356T). 
 
You asked the Plan to pre-approve a drug-eluting implant. 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 a drug-eluting implant. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the available documentation and medical literature are insufficient to support the 
use of drug-eluting implants as safe and effective, and medically reasonable and necessary in the setting of 
cataract surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a drug-eluting implant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a drug-eluting implant (0356T).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided to the 
enrollee from May 5, 2020, to June 2, 2020. 
 
You asked the Plan to pay for the SNF care. The Plan denied your request. The Plan says the enrollee no longer 
required skilled care. 
 
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 pay for the SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that there were no identifiable skilled nursing 
service needs. There were no identifiable skilled therapy service needs. The enrollee did not require skilled 
nursing or therapy services on a daily basis. The enrollee did 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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided to the enrollee from May 5, 2020, to June 2, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve continuous glucose monitor. You say that you are appealing. The Plan 
denied your request. The Plan says the denial of authorization for this device is correct, because you do not 
check your blood sugar at least 4 times per day, use insulin at least 3 times per day, or use an insulin pump. 
 
The Plan follows Medicare rules. Medicare rules say that a continuous glucose monitor is only covered when 
all 6 of the above criteria have been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continuous glucose monitor. Our 
reviewer says that you do not meet the Medicare criteria for the requested continuous glucose monitor. Our 
physician reviewer found there is no documentation that you are injecting insulin at least 4 times per day or are 
 
 
on an insulin pump, that you are checking blood sugars at least 3 times per day, or that you need frequent 
insulin dose adjustments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuous glucose monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided December 17, 2019 to December 27, 2019. 
 
You asked the Plan to pay for IRF care. You say that the enrollee was admitted on 12/17/19 after cerebral 
infarction. You are asking for reconsideration and authorization for acute inpatient rehab. The Plan denied your 
request. The Plan says the enrollee does not meet medical necessity for inpatient rehabilitation admission. 
 
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 pay for 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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record does document 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 this enrollee 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 pay for acute inpatient rehabilitation facility (IRF) admission and services provided December 17, 2019 to 
December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on 
February 24, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $40 
copayment for a specialist office visit.  
 
You have been asked to pay a $40 copayment for the specialist office visit provided. 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. Additionally, the record shows that you were billed 
in error for the remaining balance of $44.60 on your account. The provider has indicated that a reimbursement 
will be issued to you for this amount. Therefore, we decided that the Plan does not have to waive the 
copayment for the office visit (99213) provided on February 24, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continuation of SNF care. You say that the requested continuation of SNF 
care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
the continuation of SNF care. 
 
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 continuation of SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with anterior 
tibial syndrome left leg admitted to the SNF. From a nursing perspective, the enrollee received oral 
medications. This included warfarin which was dose adjusted based upon his PT/INR.  The enrollee had stable 
vital signs. He was treated for pain with effect. Regarding rehabilitation services, the enrollee received physical 
therapy and occupational therapy in the SNF.  By the dates in question, the enrollee was independent with 
 
 
functional mobility with knee scooter.  The enrollee required varying assist with activities of daily living. He 
remained non-weight bearing to his left lower extremity. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis.  This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has lung cancer and anemia 
related to chemotherapy treatment. He has not tried and failed the Plan's required drug, Retacrit. The records do 
not support that the required drug would be contraindicated or less effective; therefore, the Aranesp 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durezol eye drops. 
 
You asked the Plan to pre-approve Durezol. You say that this is the appropriate ophthalmic medication to treat 
the enrollee. 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 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 Durezol eye drops.  
 
Benefits for Durezol 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 the hereditary cardiovascular testing provided on April 22, 
2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says coverage of 
comprehensive genomic profile testing is limited to one test per specimen. 

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested for screening purposes. The records do not show that the 
results of this testing will be used to determine a specific diagnosis or treatment strategy. Medicare does not 
cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
hereditary cardiovascular testing provided on April 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services provided on October 21, 2019. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the services. The 
Plan denied your request. The Plan says the billed service cannot be verified. 
 
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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. We find that CPT code 87798 is 
not supported in the medical record. Based on this information, we decided that Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the testing services provided 
on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on December 16, 
2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99152 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services by physician also 
performing a procedure, patient 5 years of age or older, first 15 minutes. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of 
an independent trained observer to assist in monitoring the patient's level of consciousness and physiological 
status. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on 
December 16, 2019.