Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc-One injection. 
 
You asked the Plan to pre-approve the injection. You say that you need this injection to be able to get around. 
The Plan denied your request. The Plan says in order for this to be approved, treatment with other medicines 
must not have worked. 
 
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 injection. Our reviewer says that the 
requested drug is not medically reasonable or necessary and does not meet the step therapy criteria. Our 
physician reviewer found there is no evidence in the literature supporting the superiority of any of the 
 
 
hyaluronans over another in the market in their efficacy to improve pain and mobility of osteoarthritis. 
Therefore, it is not medically necessary to administer Synvisc-one instead of the other hyaluronans currently in 
the market. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Synvisc-One injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoe inserts (L3002). 
 
You asked the Plan to pre-approve the shoe inserts. You say that the inserts are medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit for the enrollee's condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve shoe 
inserts (L3002).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator rendered to you on May 29, 
2020. 
 
You asked the Plan to pay for these services. You say that you purchased the equipment. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that to suppliers must give beneficiaries the option of 
converting their capped rental equipment to purchased equipment during their 10th continuous rental month. 
 
We looked at the file and Medicare rules. The file shows that you did not rent the equipment through the Plan 
to be able to qualify for eventual purchase of the equipment. 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 portable oxygen concentrator rendered to you on May 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy (45380) 
provided on July 21, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that the colonoscopy was 
medically indicated by your physician due to a prior colonoscopy on 10/18/16 and 11/21/19 that put you at 
high risk for colon cancer as indicated by the reports. Thus the need for follow up. The Plan denied your 
request. The Plan says it was confirmed with the provider that a diagnostic colonoscopy was performed. 
Therefore, the correct copayment has been applied per the plan's Evidence of Coverage. 
 
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 $350 
copayment per date of service in outpatient hospital facility.  
 
You have been asked to pay $350 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy 
(45380) provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the optometry care. You say that you would like reconsideration because 
out-of-network care has been approved for this service in the past. The Plan denied your request. The Plan says 
these services can be provided in-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 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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Monovisc injection (J7327) provided July 
6, 2020. 
 
You asked the Plan to waive the copayment for the injection. You say that you should not be responsible for 
the coinsurance. The Plan denied your request. The Plan says the correct cost-sharing 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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay a 20% coinsurance ($316.50) for the injection. The injection falls within the Part B 
drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a Monovisc injection (J7327) 
provided July 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for infrared therapy provided from March 
7, 2020, through March 17, 2020. 
 
You asked the Plan to make additional payment for the infrared therapy. You say that you are requesting 
reimbursement of the $875 paid. The Plan denied your request. The Plan says the correct amount was 
reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that non-contract providers must accept as payment 
in full payment amounts applicable in Original Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for more 
payment of infrared therapy have not been met. The plan has paid the Medicare allowable, which is the most 
that the law requires the Plan to pay. Therefore, we decided that the Plan does not have to make additional 
payment for infrared therapy provided from March 7, 2020, through March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a general health panel (80050) performed 
on June 17, 2020. 
 
You asked the Plan to waive the deductible for a general health panel. You say that you feel this charge is 
exorbitant. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible for Medicare-covered laboratory tests.  
 
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests 
and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $250 deductible for Medicare-covered laboratory tests. This cost 
sharing is a contractual obligation that had not been met at the time a general health panel was performed on 
June 17, 2020. Therefore, we decided that the Plan does not have to waive the deductible for a general health 
panel (80050) performed on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0823). 
 
You asked the Plan to pre-approve the power wheelchair. You say that the chair is medically necessary. The 
Plan denied your request. The Plan says insufficient documentation was provided. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file did not include any documentation or proof of an evaluation to show that the enrollee is capable of 
safely operating the requested PMD in the home. This means that Medicare rules for coverage of a PMD have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0823).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatological services (99213, 69100) provided on 
February 22, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the dermatological services. You say that you did not know this service would 
not be covered. The Plan denied your request. The Plan says prior authorization was not obtained by the facility 
or the provider; therefore, payment has been correctly denied. 
 
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 dermatological services (99213, 69100) 
provided on February 22, 2019, by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that the enrollee cannot walk 
independently. The Plan denied your request. The Plan says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 8 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee has had prior therapy for this 
condition and additional visits have already been authorized to allow for review of an independent exercise 
program. Our reviewer says that the unique skills of a professional therapist are not required to safely and 
effectively provide ongoing treatment. 
  
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total hip arthroplasty. 
 
You asked the Plan to pre-approve total hip arthroplasty. You say that the requested total hip arthroplasty is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested total hip arthroplasty. 
 
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 total hip arthroplasty. Our reviewer 
says that the enrollee does not meet criteria for the requested total hip arthroplasty. Our physician reviewer 
found this enrollee presents with complaints of right knee and hip pain. Functional mobility is limited. Clinical 
exam findings are consistent with reported radiographic findings of complete collapse of the joint space 
consistent with end-stage osteoarthritis. She has failed to improve with activity modification, ambulatory 
assistive device, and medications. She has a history of prior urosepsis and hospitalization in 2019. She has a 
positive current nares swab for MSAA. Pre-operative lab testing does not evidence a urinalysis. Under 
consideration is a request for total hip replacement. Medicare criteria have not been currently met in the setting 
of possible active bacteremia or possible urinary tract not clearly addressed by the submitted medical records. 
Therefore, the enrollee does not have a covered indication for the requested total hip arthroplasty at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve total hip arthroplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care from 10:01 AM on January 6, 2020, through 
January 10, 2020. 
 
You asked the Plan to pay for inpatient care. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee was stable for transfer by 10:00 AM on January 6, 2020. 
 
 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient care. Our reviewer says that the 
criteria for coverage of these services have not been met. Our physician reviewer found by 10:00 am on 
January 6, 2020, the enrollee had been noted to be awake and alert, had her facial laceration repaired, had been 
admitted as inpatient for Comfort Care, and the neurosurgeon had determined that no surgical intervention was 
indicated. The enrollee remained stable throughout her remaining inpatient stay without having any acute, 
actionable medical issues. The review indicates that the enrollee did not transfer to a Plan facility until January 
10, 2020, because it was documented daily that her children were considering enrolling her into Hospice. All 
inpatient care provided after 10:00 am on January 6, 2020, through transfer at 10:15 pm on January 10, 2020, 
was not needed on an emergent basis. The review has determined that the treating physician did not document 
that the patient was not stable for transfer on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient care from 10:01 AM on January 6, 2020, through January 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment forthe esophagogastroduodenoscopy provided on March 6, 2020.You asked the Plan to adjust the copayment forthe esophagogastroduodenoscopy. You say that you should only have a specialist copayment.The Plan denied your request. The Plan says you were charged the coinsurance correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance foranoutpatient ambulatory surgery visit.You have been asked to pay 20% coinsurance for the esophagogastroduodenoscopy. The esophagogastroduodenoscopy falls within the Outpatient Ambulatory Surgery Visitbenefit 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 doesnot have to adjust the copayment forthe esophagogastroduodenoscopy provided on March 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tissue exam by pathologist (88305) provided on June 30, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for tissue exam. You say that you provide services on specimen other providers send 
to you. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 tissue exam by pathologist (88305) provided 
on June 30, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient stay (0121, 0250, 0301, 0305, 0306, 0307, 0320, 0352, 0424, 0444) provided on December 25, 2019 to December 27, 2019 by an out of network (OON) provider.You asked the Plan to pay forinpatient stay. You say that the services rendered were medically necessary.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.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 forthe inpatient stay (0121, 0250, 0301, 0305, 0306, 0307, 0320, 0352, 0424, 0444) provided on December 25, 2019 to December 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient home visit (99349) provided on April 
6, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient home visit. You say that prior authorization is not needed 
for services rendered under telemedicine. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 established patient home visit (99349) 
provided on April 6, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 2, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service requires 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 laboratory services provided to the enrollee on 
July 2, 2020.