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


We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar (CPT Code 22514).

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 Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The member's medical records show that the member's initial fracture was said to occur on September 20, 2020, which has been more than six (6) weeks. The rules say that PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with BOTH the following: 1. Inclusion criteria (ALL are required): a. Acute* (less than 6 weeks) osteoporotic VCF (T5 - L5) by recent (within 30 days) advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake). Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar (CPT Code 22514).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta (J3304). 
 
You asked the Plan to pre-approve Zilretta. You say that the medication is necessary. The Plan denied your 
request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 Zilretta. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the package insert does not contain a limitation in the use of Zilretta to being used only after the 
failure of another steroid. The package insert also notes slow release causes less blood sugar elevation. The 
requested medication is medically reasonable and 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 Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
Zilretta (J3304).  
 
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 wound debridement services you had at an 
outpatient hospital facility from February 19, 2020, to March 25, 2020. 
 
You asked the Plan to waive the copayments for the wound debridement services. You say that this cost 
sharing is a hardship for you.  You say that these services only took 30-60 minutes each and that you were not 
an inpatient. The Plan denied your request. The Plan says you were charged these copayments 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 $270 
copayment for surgery or other services you receive in an outpatient hospital facility.  
 
Records show that you had three separate visits for wound debridement at an outpatient hospital facility.  
Wound debridement is considered a surgical service. You have been asked to pay a $270 copayment for each 
of the wound debridement services. The wound debridement services fall within the surgery or other services 
you receive in an outpatient hospital facility. 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 copayments 
for wound debridement services you had at an outpatient hospital facility from February 19, 2020, to March 25, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received from January 6, 2020, to April 17, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is non-
certified Medicare provider. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program.  
 
We looked at the file and Medicare rules. The provider in question does not participate in the Medicare 
program and therefore is not payable for these services. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the services you received from January 6, 2020, to April 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRFadmission and services.You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare guidelines the enrollee does not meet coverage criteria for an IRF 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 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 based on the documentation provided, the health plan's denial should be upheld.The enrollee does not require the intensity of services provided at an IRF.Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.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 IRFadmission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network outpatient mental health services provided to 
the enrollee on May 7, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 provider in this case is not a network provider with the Plan. 
The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not 
pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for out of network outpatient mental health services 
provided to the enrollee on May 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea nuclear stress test.You asked the Planto pre-approvethe test. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not the standard test for your condition.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 indenying the request to pre-approve the test. Our reviewer says that the requested test is not considered medically reasonable and necessary in this case. Our physician reviewer found you have some coronary risk, exertional dyspnea with no angina, a normalcardiac physical exam, a normal electrocardiogram, normal left ventricular function on echocardiography and a normal exercise stress test about 1 1/2 years ago. In this circumstance, if reevaluation with repeat stress testing is thought to be medically necessary then repeat exercise electrocardiography would be a reasonable and appropriate initial test. Coverage criteria for nuclear stress test is not met since there are no documented covered indications for the procedure.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 test have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea nuclear stress test.
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 for the enrollee. 
 
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 it appears that this is an unsafe discharge from an acute care setting at 
this time. 
 
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 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care 
needs can be met at a lower level of care. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
July 27, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician 
services provided to the enrollee on July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on June 18, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you were told that 
you could try this for 2 weeks for free. You say that you thought the machine was uncomfortable. The Plan 
denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for durable medical equipment/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $304. The total amount you are being asked to pay is $60.80 ($304 x 20% = $60.80). 
Since durable medical equipment was provided, the correct copayment has been applied. Durable medical 
equipment falls within the durable medical equipment/in-network 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 durable medical equipment provided by a participating provider on June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are not able to stand in the shower. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract removal services provided on June 2, 2020. 
 
You asked the Plan to pay for the cataract removal services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that services provided in freestanding emergency 
departments are only covered if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. Review of the file shows that the provider is a non-Medicare 
approved/certified freestanding facility. Based on this information, we decided that Medicare rules for coverage 
of the cataract removal services have not been met. Therefore, we decided that the Plan does not have to pay 
for the cataract removal services provided on June 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 genetic testing. 
 
You asked the Plan to pay for the Guardant360 genetic testing. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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, Medicare guidelines say when billing for the Guardant360 molecular lab panel, procedure code 
81479 is the only code available for billing. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the Guardant360 genetic testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer. 
 
You asked the Plan to pre-approve Insertion of Interlaminar/Interspinous Process Stabilization/Distraction 
Device (22869) and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870). 
You say that conservative therapy is not working for your chronic low back and leg pain. The Plan denied your 
request. The Plan says the Vertiflex Superion Device is considered experimental and investigational. 
 
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 Insertion of Interlaminar/Interspinous 
Process Stabilization/Distraction Device (22869) and Insertion of Interlaminar/Interspinous Process 
Stabilization/Distraction Device (22870). Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device 
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 Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device 
(22869) and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient hospital services you 
received on May 28, 2020, to May 29, 2020, and the emergency room (ER) visit you had on June 21, 2020. 
 
You asked the Plan to waive the copayments for the outpatient hospital services and the ER visit. You say that 
you are not sure that these bills are correct. The Plan denied your request. The Plan says you were charged 
these copayments 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 $300 
copayment for outpatient hospital services and a $90 copayment for ER visits.  
 
You have been asked to pay a $300 copayment for the outpatient hospital services and a $90 copayment for the 
ER visit. This means that you have been asked to pay the correct amounts 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 outpatient hospital services you received 
on May 28, 2020, to May 29, 2020, and the emergency room (ER) visit you had on June 21, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that you inject insulin 3-4 times a 
day depending on how well you are controlling your blood sugars. The Plan denied your request. The Plan says 
that you are not insulin-treated with multiple daily injections. 
 
The Plan follows Medicare rules. Medicare rules say that a continuous glucose monitor is 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 a continuous glucose monitor. Our 
physician reviewer found that you check your blood sugars 3-4 times daily. You have intermittent 
hypoglycemia. Based on the records provided, the requested monitor is indicated, and medically reasonable. 
 
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 continuous glucose monitor have been met. Therefore, we decided that the 
Plan has to pre-approve a continuous glucose monitor.  
 
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: 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 need to be in a hospital for rehabilitation 
because your potassium levels are inconsistent which needs to be monitored and treated while you receive your 
therapy. The Plan denied your request. The Plan says you are not currently medically stable to be released from 
the current acute care hospital. IRF care is not medically reasonable at this time. 
 
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 patient was admitted for congestive heart failure. Medical problems are stable. 
There are no identified problems that need inpatient medical management. There are no complex nursing or 
rehabilitation needs. 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 this 
patient 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.