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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from
October 1, 2019 to October 10, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that SNF claims must be billed with a PDPM revenue
code.
We looked at the file and Medicare rules. The claim for the SNF services was not billed with the required
PDPM revenue code. 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 skilled nursing facility
(SNF) services rendered from October 1, 2019 to October 10, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. You say that the requested medication is necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy
exception has not been 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 Euflexxa. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found the documentation does not support that
Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse
effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa (J7323).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide.
You asked the Plan to pre-approve a home health aide. 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 HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.
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 home health aide. Our reviewer says
that the services are not medically necessary. Our physician reviewer found the records do not show that skilled
nursing services or skilled therapy services are required to effectively provide treatment, care, and/or services
in order to improve your condition, or to establish/perform a maintenance program to maintain your condition
and/or prevent deterioration. The services do not meet the definition of home health aide services as per 50.2 as
the documentation does not reveal that leaving the home is a significant and taxing effort indicating a home
bound status. Also the documentation does not reveal that you are currently receiving home health skilled
nursing or skilled therapy services. Therefore, the request for the home health aide is not medically necessary.
Home health aide services are not reasonable and necessary to the treatment of your illness or injury by the
skilled professional staff.
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 home health aide have not been met. Therefore, we decided that the Plan does
not have to pre-approve a home health aide.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic visits for the enrollee.
You asked the Plan to pre-approve the visits.. You say that the adjustments help relieve pain. The Plan denied
your request. The Plan says there is little in the way of objective findings documented.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
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 visits. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the only treatment
allowed by Medicare for chiropractors is to treat a subluxation of the spine. The subluxation may be
demonstrated by x-ray or by physical examination. There are no submitted imaging studies to reveal evidence
of a subluxation. The submitted chart notes/office visit notes, handwritten and very difficult to read, are from
August 20, 2019 through May 11, 2020 reveal, mainly, how the enrollee feels that day, notations regarding
treatment such as myofascial release, soft tissue manipulation, trigger point therapy and ultrasound therapy to
certain areas such as as L5 and S1 and the tensor fascia lata. The submitted examination of June 1, 2020 reveals
several positive orthopedic tests, muscle spasms of several muscles, trigger points of several muscles, pain
upon ranges of motion of several muscles and hypoesthesia (via pinwheel) of the right leg. These findings do
not reveal evidence of a subluxation per Medicare guidelines. Thus, chiropractic treatment is neither supported
nor allowed per Medicare guidelines.
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 visits have not been met. Therefore, we decided that the Plan does not have
to pre-approve chiropractic visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 19, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the outpatient visit (99204). You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says all medically necessary services are
available in your network and there are no extenuating circumstances making it medically necessary to obtain
the service out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on November 19,
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided at the in-network
benefit level.
You asked the Plan to pre-approve physician's services to be provided at the in-network benefit level. You say
that a prostate cancer specialist who only sees prostate cancer patients is not available with an in-network
provider. The Plan denied your request. The Plan says services provided by a non-contract provider are only
approved at the in-network benefit level when the services are not available through the Plan's provider
network.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve
physician's services to be provided at the in-network benefit level.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from
November 7, 2019 to December 12, 2019.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you should not have
to pay this bill because you were told that the Plan would pay for therapy. 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 $40
copayment for Medicare-covered in-network physical therapy and speech therapy service.
You have been asked to pay a $40 copayment for each of the physical therapy visits. The physical therapy visit
falls within the "Outpatient rehabilitation 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
copayments for the physical therapy visits provided from November 7, 2019 to December 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 14, 2019.
You asked the Plan to pay for the ambulance services. You say that you were immobile from an automobile
accident and this transport was a must. 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 pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination.
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 14,
2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services or pay for self-administered drugs provided on November 27, 2019.
You asked the Plan to waive the copayment for outpatient hospital services and pay for the self-administered
drugs. You say that you would like reconsideration because the only reason the member was not admitted
inpatient was because there was not a room available. The Plan denied your request. The Plan says this claim
processed correctly according to the member's benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $400 copayment for each visit to an outpatient hospital facility.
The enrollee has been asked to pay a $400 copayment for the outpatient hospital services. This means that the
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Additionally, 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 waive the copayment for outpatient hospital services or pay for self-administered
drugs provided on November 27, 2019.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 7, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without 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 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 the medical services provided on January 7, 2020
by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria has not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1851).
You asked the Plan to pre-approve the orthosis. You say that the enrollee requires the orthosis. The Plan denied
your request. The Plan says the documentation does not support Medicare coverage criteria.
The Plan follows Medicare rules. Medicare rules say that a knee orthosis indicated can only be covered if there
is documented knee instability and joint laxity.
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 orthosis. Our reviewer says that the
service is not medically necessary. Our physician reviewer found there is no documentation in the records of an
objective description of joint laxity. The records indicate "all ligaments appear stable."
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 orthosis have not been met. Therefore, we decided that the Plan does not
have to pre-approve a knee orthosis (L1851).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care provided December 3 to
December 10, 2018.
You asked the Plan to pre-approve the inpatient care. You say that the services were medically necessary. The
Plan denied your request. The Plan says the claim form did not reflect the correct dates of service.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that
Medicare coverage criteria have been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of inpatient hospital care have not been met. Specifically, the dates of service approved do not match
the dates billed on the claim form. Therefore, we decided that Medicare rules for coverage of the inpatient care
have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital care
provided December 3 to December 10, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on February 5, 2020 to
February 6, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you did not bring your medicine to the
hospital with you because they told you to leave all of your medications at home. You also say that you do not
think you should be held responsible for the bill. The Plan denied your request. The Plan says these drugs are
self-administered and not covered by Medicare 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 pay for the self-administered drugs
provided on February 5, 2020 to February 6, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to reduce the cost for the tissue exam. We decided that the Plan does not have to
waive the cost for the tissue exam.
You asked the Plan to waive the cost for the tissue exam. You say that you did not see this doctor. You say that
you are being double charged. The Plan says that the copayment applied correctly.
We decided that the Plan has to reduce the cost for the tissue exam.
The Plan says that you must a $40 copayment for the tissue exam. The tissue exam is considered a laboratory
service. Based on the Plan contract, you cannot be asked to pay more than 20% of the allowed amount for the
tissue exam. The allowed amount is $41.13 (20% x $41.13 = $8.22). Therefore, we decided that the Plan has to
reduce the cost for the tissue exam.
We also decided that the Plan does not have to waive the cost for the tissue exam.
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 in-network, Medicare-covered lab services. Therefore, we decided that the Plan does not have to
waive the cost for the tissue exam.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that because of chronic conditions the
enrollee needs incontinence supplies. The Plan denied your request. The Plan says this item is not a covered
benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on January 3, 2020.
You asked the Plan to pay for the endodontic therapy. You say that these services were emergent and
necessary. The Plan denied your request. The Plan says the root canal provided to you was a Class III service.
The Plan also says that this service was rendered prior to your 12 month waiting period that had started on
January 1, 2020.
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, when you enroll in the optional
supplemental benefits, there may be a waiting period. The EOC shows that endodontic therapy (root canal
therapy) is considered a Class III service and there is a 12 month waiting period before these services will be
covered by the Plan. The record shows that you received the endodontic therapy prior to the end of the 12
month waiting period. Therefore, we decided that the Plan does not have to pay for the endodontic therapy
provided on January 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wrinkle removal (rhytidectomy) on the forehead
(15824) and neck (15825).
You asked the Plan to pre-approve wrinkle removal on the forehead and neck. You say that this is medically
necessary for the enrollee's gender affirmation. The Plan denied your request. The Plan says these services are
cosmetic by nature and non-covered.
The Plan must follow Medicare rules. Medicare rules say that rhytidectomy represented by CPT codes 15824
and 15825 is a non-covered service.
We looked at the file and Medicare rules. The requested services are listed as non-covered procedures. Based
on this information, we decided that Medicare rules for coverage of wrinkle removal on the forehead and neck
have not been met. Therefore, we decided that the Plan does not have to pre-approve wrinkle removal
(rhytidectomy) on the forehead (15824) and neck (15825).