Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Feraheme infusions. 
 
You asked the Plan to pre-approve Feraheme infusions. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the documentation does not show the enrollee has failed oral iron 
therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Feraheme infusions. Our reviewer says 
that the requested Feraheme infusions are medically necessary. Our physician reviewer found after bariatric 
surgery, patients do not absorb iron given orally. They require intermittent parenteral iron to keep their iron 
stores up to prevent iron deficiency anemia. Some patients become fatigued with low iron stores prior to the 
onset of anemia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme infusions have been met. Therefore, we decided that the Plan has to 
pre-approve Feraheme infusions.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. The Plan denied your request. The Plan says there is no 
documentation that the MRI has been ordered by your physician. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We looked at the file, and Medicare rules. In this case, there is insufficient medical records to show that the 
requested imaging is medically reasonable or necessary. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve 
magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty. 
 
You asked the Plan to pre-approve a total knee arthroplasty. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a total knee arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you present with a history of bilateral knee pain. There is clinical evidence reported 
consistent with radiographic evidence of mild to moderate loss of joint space along both medial and lateral 
compartments, and moderate loss anteriorly. Current evidence based medical guideline criteria have not been 
fully met to support this request. There is evidence of body mass index less than 40 and imaging evidence of 
moderate right knee osteoarthritis. However, current pain and functional assessment relative to the right knee 
has not been documented. Physician records do not discuss right knee comprehensive, recent conservative 
treatment trial and failure. Therefore, you do not have a diagnosis, condition and/or symptoms that meet 
Medicare criteria for total knee arthroplasty at this time. Total knee arthroplasty would not be considered the 
standard of care and medically reasonable and necessary for treatment of your medical condition. 
 
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 total knee arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee arthroplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that tooth #3 is fractured due to a defective 
restoration. The Plan denied your request. The Plan says core buildup is not a covered service. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
core buildup, including any pins when required (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint nerve destruction (64635, 64636, 99214). 
 
You asked the Plan to pre-approve facet joint nerve destruction. You say that you need this because the initial 
shots had minimal results. The Plan denied your request. The Plan says the records are insufficient to support 
this is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that destruction of cervical, thoracic or lumbar 
paravertebral facet joint (median branch) nerves will not be considered medically reasonable and necessary 
when the medical records do not support that the patient experienced temporary or prolonged abolition of the 
pain after a facet joint nerve block injection. 
 
We looked at the file and Medicare rules. The submitted medical records indicate that your previously received 
this service, but do not include documentation of the effectiveness. Without this information, it cannot be 
determined that this service is medically necessary. Based on this information, we decided that Medicare rules 
for coverage of facet joint nerve destruction have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint nerve destruction (64635, 64636, 99214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that the records received show that the 
enrollee's condition has improved and the enrollee is no longer a threat to yourself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the 
enrollee in this case. The patient does not meet the criteria for continued acute inpatient mental health treatment 
for the dates in question of October 20, 2020 forward as this patient was not shown to be a danger to herself or 
others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with 
treatment while not showing any threat to safety. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for inpatient psychiatric hospital services. 
 
 
 
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 psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for eye examinations provided from May 7, 
2019, to November 5, 2019. 
 
You asked the Plan to waive the copayments for eye exams. You say that your copayment for a specialist is 
only $35. The Plan denied your request. The Plan says the copayment amounts you are being charged are 
correct. 
 
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 $40 
copayment for each ophthalmology visit. There were 3 visits, resulting in a total copayment obligation of $120. 
 
You have been asked to pay $40 copayment for each eye exam. Eye exams fall within the Vision Care 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 eye examinations provided from May 7, 2019, 
to November 5, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Cardiac Positron Emission Tomography (PET) scan (78814). 
 
You asked the Plan to pre-approve the Cardiac PET scan. You say that the PET scan is medically necessary. 
The Plan denied your request. The Plan says that 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 the Cardiac PET scan. Our reviewer 
says that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has known pulmonary sarcoidosis, cardiac symptoms and a recent echocardiogram 
suggesting possible cardiac sarcoidosis. The next indicated study to assess for cardiac sarcoid is FDG PET 
scanning which is what has been requested by the provider. This is medically necessary and indicated under 
Medicare rules. 
 
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 Cardiac PET scan have been met. Therefore, we decided that the Plan has to 
pre-approve a Cardiac Positron Emission Tomography (PET) scan (78814).  
 
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 pay for the initial observation care (99220) provided on May 24, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for initial observation care. You say that the services 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 for the initial observation care (99220) provided on 
May 24, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs physical therapy and occupational 
therapy to regain strength to reach baseline to go home. The Plan denied your request. The Plan says care can 
safely be received in other settings. 
 
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 the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. Our reviewer says that while the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program.  
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided to the enrollee on January 16, 2020.You asked the Plan to pay forthe visit. The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that the phrase "new patient" is interpreted to mean a patient who has not received any professional services from the physician or physician group practice within the previous 3 years. We looked at the file and Medicare rules. The records show that the enrollee was provided services by this provider within the last 3 years. This means that the enrollee is not considered a new patient and it is inappropriate to bill a new patient office visit. Based on this information, we decided that Medicare rules for coverage of the visit have not been met.Therefore, we decided that the Plan does not have to pay forthe office visit provided to the enrollee on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Afirma test provided on May 14, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the Afirma test. You say that the Afirma test following an indeterminate 
cytology diagnosis was medically necessary. The Plan denied your request. The Plan says the services were 
rendered by a non-network provider. The Plan also says that the services were not approved in advance. 
 
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 Afirma test provided on May 14, 2020 by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the DME to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the services are available by a provider in the Plan's 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 DME to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on May 1, 2020. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on May 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF care and that a 
lower level of care is not appropriate at this time. The Plan denied your request. The Plan says rules for IRF 
care have not been met. 
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record does document a need for physical and occupational therapy, it does not document a 
need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Monovisc injection provided on June 
11, 2019. 
 
You asked the Plan to waive the copayment for the Monovisc injection. You say that you have been getting this 
shot for 9 years and never paid this much. You say that the amount should be reduced to something you can 
afford. The Plan denied your request. The Plan says the coinsurance applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of 
the Medicare-allowed amount for Medicare Part B-covered drugs. 
 
You have been asked to pay $595.29, which is 20% of allowed amount for the Monovisc injection. The 
allowed amount is $2,976.46 (20% x $2,976.46 = $595.29). The Monovisc injection falls within the "Medicare 
Part B prescription 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 the 
Monovisc injection provided on June 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea semi-electric hospital bed with side rails and mattress.You asked the Plan to pre-approvea semi-electric hospital bed with side rails and mattress. You say that the enrollee needs a semi-electric hospital bed.The Plan denied your request. The Plan says the doctor's notes do not show the enrollee meets criteria for a semi-electric hospital bed.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 semi-electric hospital bed. Our reviewer says that a semi-electric hospital bed is not medically necessary. Our physician reviewer found the documentation does not clearly reveal that enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a clear medical need for an immediate change in body position or special attachments that cannot be fixed on an ordinary bed in the medical progress notes. The head of the bed does not need to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. The request for a semi-electric hospital bed is not medically necessary for this enrollee.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 semi-electric hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approvea semi-electric hospital bed with side railsand mattress.