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

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you fell and needed help, but did not need 
to go to the hospital. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 17, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta Onpro (CPT Code J2505). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the member is in a clinical trial. 
 
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 medication have not been met. The rules say that claim 
payment for managed care plan members for the covered routine costs associated with a clinical trial is the 
responsibility of the original Medicare contractor, and not the managed care plan. The claims for routine costs 
associated with this clinical trial are not payable by the member's Plan. Therefore, we decided that the Plan 
does not have to pre-approve Neulasta Onpro (CPT Code J2505).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve a prosthetic leg. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says that there are in-network providers that are able to service this 
member's needs. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a prosthetic leg to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided on May 1, 2020, 
through May 6, 2020. 
 
You asked the Plan to pay for the occupational therapy services. You say that you would like reconsideration 
because the services rendered were medically necessary. The Plan denied your request. The Plan says payment 
for these services are included in the facility PPS payment. 
 
The Plan must follow Medicare rules. Medicare rules say that physical therapy, speech-language pathology 
services, and occupational therapy are bundled into the SNF?s global per diem payment for a resident?s covered 
Part A stay. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the record indicates that the 
member was in an SNF on the billed dates of service. Payment for this service is bundled into the payment to 
the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not 
have to pay for occupational therapy services provided on May 1, 2020, through May 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from June 15, 2020, to July 6, 2020 
and July 12, 2020, to July 14, 2020. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that the enrollee 
did not necessitate skilled services during this time as clinically the enrollee's condition no longer required 
daily skilled services at an inpatient skilled nursing facility (SNF) level of 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 services. Our reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found that based on the 
documentation provided the enrollee no longer qualified for SNF coverage after June 14, 2020. The enrollee did not have documented skilled nursing needs. The enrollee did not have 
documented skilled therapy needs. The enrollee was at his baseline level of function. Daily skilled services 
were not required to establish a maintenance program or to prevent deterioration of the enrollee's 
condition. The enrollee's care needs at this point were custodial and, as a practical matter, could be provided at 
a lower level of care (ex. home, AL, LTC). 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pay for SNF services provided from June 15, 2020, to July 6, 2020 and July 12, 2020, to July 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the 
enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The 
Plan says under Medicare, this request 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 
complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There 
is not a reasonable expectation that this individual will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. 
 
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 
admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve percutaneous sacral augmentation (sacroplasty), unilateral 
injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes 
imaging guidance and bone biopsy, when performed (CPT Code 0200T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that there is insufficient evidence that it is effective when used for sacral 
fractures. 
 
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 the service. Our reviewer says that the requested items/services 
are considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee had 
a history of multiple falls resulting in fractures. The enrollee had a recent fall on September 12, 2020, that 
resulted in significant sacral fractures, right worse than left. There are confirmatory findings on bone scan and 
computed tomography (CT) scan imaging of bilateral sacral fractures, with findings consistent with 
insufficiency fractures. The enrollee reports on-going pain and difficulty with ambulation. The enrollee had 
failed to improve with over two (2) months of activity modification, medications, and physical therapy. Under 
consideration is a request for percutaneous vertebroplasty of the sacrum (sacroplasty). Current evidence based 
medical literature supports the use of sacroplasty as safe and effective for treatment of sacral insufficiency 
fractures. Therefore, this request for sacroplasty 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 the service have been met. Therefore, we decided that the Plan has to pre-approve percutaneous 
sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, 
when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed (CPT Code 
0200T).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan soft tissue neck; with contrast material(s) (CPT 
Code 70491) and CT scan thorax; with contrast material(s) (71260). 
 
You asked the Plan to pre-approve the CT scans. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the CT scans. Our physician reviewer 
found regarding the requested CT scan soft tissue neck; with contrast material(s) (70491): Repeat imaging 
studies are not generally necessary unless there is evidence of disease progression, recurrence of disease, and/or 
the repeat imaging will affect a patient's clinical management. In this case, the clinical information provided 
does not meet these criteria. CT imaging of any body part that showed involvement of the head and neck 
cancer are supported once within six months of completing all treatment. The clinical information provided 
does not describe this imaging time frame and, therefore, the request is not indicated at this time. Regarding the 
requested CT scan thorax; with contrast material(s) (71260), the records indicate that the patient has been 
treated for cancer of the head or neck. Repeat imaging studies are not generally necessary unless there is 
evidence of disease progression, recurrence of disease, and/or the repeat imaging will affect a patient's clinical 
management. The clinical information provided does not meet these criteria and, therefore, the request is not 
indicated at this time. CT imaging of any body part that showed involvement of the head and neck cancer are 
supported once within six months of completing all treatment. The clinical information provided does not 
describe this imaging time frame and, therefore, the request is not indicated at this time. The review has 
determined that the requested CT Scans are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scans have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CT scan soft tissue neck; with contrast material(s) (CPT Code 70491) and CT scan thorax; 
with contrast material(s) (71260).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided on August 3, 2020. 
 
You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like reconsideration 
because the lab rendered the services ordered by the physician. The Plan denied your request. The Plan says 
Medicare denies coverage for all cardiovascular risk assessment panels. 
 
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 test at issue in this appeal, the cardiovascular risk assessment, is cardiovascular risk assessment beyond the 
basic lipid panel. Medicare does not cover cardiovascular risk assessment panels, except the basic lipid panel 
for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the 
Plan does not have to pay for cardiovascular risk assessment testing provided on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services 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 the medical services provided to the enrollee by an out-of-network provider 
on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services (36415, 86140, 85025) 
provided June 2, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that the copayment should be waived 
The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for lab services.  
 
You have been asked to pay a $10 copayment for the lab services. 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 lab services (36415, 86140, 85025) provided June 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant 360 testing provided to the enrollee on May 28, 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 claim was not submitted with the required codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare has specific code requirements for this 
type of testing. In this case the claim submitted does not contain the required codes. Medicare billing criteria 
are not met. Therefore, we decided that the Plan does not have to pay for Guardant 360 testing provided to the 
enrollee on May 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroscopy, knee, surgical; with meniscectomy (medial 
AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage 
(chondroplasty), same or separate compartment(s), when performed (CPT Code 29880). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee presents with persistent grade 9/10 left medial knee pain with associated 
weakness, popping, and snapping. Pain increased with activities of daily living. Clinical exam findings are 
consistent with imaging evidence of a complex medial meniscus tear and patellofemoral joint degenerative 
changes. The enrollee has failed to improve with conservative treatment, including activity modification, 
medications, ice, heat and bracing. Authorization was requested for left knee arthroscopy with chondroplasty 
and meniscectomy (CPT codes 29877 and 29880). The enrollee has been approved for left knee chondroplasty 
(CPT code 29877). The medical necessity of CPT code 29880 (left knee medial AND lateral meniscectomy) is 
not established. There is no evidence of lateral meniscus pathology on clinical exam or imaging to support 
surgical treatment. Therefore, the request for knee surgery (CPT code 29880) is not 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any 
meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate 
compartment(s), when performed (CPT Code 29880).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultra lightweight manual wheelchair (K0005) and 
related accessories. 
 
You asked the Plan to pre-approve the ultra lightweight wheelchair. You say that the enrollee requires it 
because her arms ache. The Plan denied your request. The Plan says the lightweight wheelchair is not covered 
based on the records provided. 
 
The Plan follows Medicare rules. Medicare rules say that  
 
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 ultra lightweight wheelchair. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
does not clearly reveal that the patient is unable to perform MRADLs effectively in a standard wheelchair. The 
documentation does not reveal consistent upper extremity findings that indicate this patient would be unable to 
 
 
operate a standard manual wheelchair. The documentation does not support that the requested Smart Drive 
MX2+ is safe for this patient to use in the home and participate in MRADLs in the home. 
 
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 ultra lightweight wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve ultra lightweight manual wheelchair (K0005) and related accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the physician services provided on July 16, 2020, 
by an out-of-network provider. 
 
You asked the Plan to reimburse you for the physician services. You say that you have to see this doctor 
because of your medication. The Plan denied your request. The Plan says you did not request prior 
authorization. 
 
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 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 reimburse you for the physician services provided on July 16, 2020, by an out-of-network 
provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX (CPT Code J7321). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says you must meet the following criteria: has tried and cannot use Orthovisc and 
Monovisc. 
 
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 medication. Our physician reviewer 
found the review has determined that the Plan requires a trial of drug Orthovisc and Monovisc before they will 
approve the requested drug.  In this case, you have not tried and failed the required drug(s). There is no 
documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely 
 
 
have adverse effects for you. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX (CPT Code J7321).