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

We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural injections. The Plan denied your request. The Plan says the enrollee 
needs at least 2 months or longer between epidural injections. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 epidural injections. Our physician 
reviewer found that the enrollee has chronic neck pain. She is status post cervical spine surgery. She takes 
Gabapentin, Hydrocodone and Meloxicam for pain and has had 2 prior epidural steroid injections. The first 
produced excellent pain relief. A second epidural steroid was performed, but the degree of pain relief is not 
documented. A request for another epidural steroid injection is made less than one month later. There is a lack 
of documentation showing the results of the second injection, or why another injection is needed so soon after. 
Therefore, the request is not medically reasonable or necessary 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 epidural injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve epidural steroid injections.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee no longer require daily skilled services. 
 
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 pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OPDIVO 240 mg/24 mL vial. 
 
You asked the Plan to pre-approve OPDIVO. You say that this service is medically necessary. The Plan denied 
your request. The Plan says the requested use of the drug is not a medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 OPDIVO. Our reviewer says that this 
service is not medically reasonable and necessary. Our physician reviewer found this is a 75-year-old woman 
with colon cancer and several prior lines of therapy. The requested use of OPDIVO is not FDA-approved for 
the enrollee's condition. Furthermore, major drug compendia or clinical research that appears in a CMS-
approved medical journal do not support the requested use of this drug. The cited study is only so far at phase 
1. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OPDIVO have not been met. Therefore, we decided that the Plan does not have 
to pre-approve OPDIVO 240 mg/24 mL vial.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation trips. You say that the requested transportation is 
necessary. The Plan denied your request. The Plan says based on the documentation provided, 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 one-way trip to the home for continued acute care after discharge from an emergency 
room and any additional trips to a physician related to the continued acute home care 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan?s rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy for an anterior tooth (D3310) for 
tooth # 11. 
 
You asked the Plan to pre-approve the dental service. You say that you called the Plan regarding your dental 
benefit. You say that you were advised that you had $2,000 for dental coverage. You also say that you were not 
advised that root canals were not covered. The Plan denied your request. The Plan says endodontic therapy for 
an anterior tooth is listed with NC, or not covered. 
 
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 
endodontic therapy for an anterior tooth (D3310) for tooth # 11.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from August 26, 
2020, to September 2, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges because of coding discrepancies and you cannot afford the charges. The Plan denied your request. The 
Plan says the claims were processed correctly, and you are being charged the correct 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 $375 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from August 26, 2020, to September 2, 2020. Therefore, you are responsible 
to pay a $375 copayment for days 1-5 (August 26, 2020, to August 30, 2020). $375 (copayment) x 5 (inpatient 
days) = $1,875.00. 
 
You have been asked to pay the total copayment amount of $1,875.00 for an inpatient hospital stay. An 
inpatient hospital stay falls within the inpatient hospital 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 copayment for an inpatient hospital stay from August 26, 2020, to September 2, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from June 1, 2020, to 
June 11, 2020. 
 
You asked the Plan to waive the copayment for SNF care. You say that you received limited physical therapy 
while you were in isolation for 14 days. You also say that you would like to be reimbursed for your prolonged 
stay at the SNF. The Plan denied your request. The Plan says the copayment amount you are being charged is 
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 a $0 
copayment per day for days 1 to 20, and a $50 copayment per day for days 21 to 100 for Skilled Nursing 
Facility (SNF) care. This SNF stay lasted 10 days, resulting in a total copayment amount of $500. 
 
You have been asked to pay a $0 copayment per day for days 1 to 20, and a $50 copayment per day for days 21 
to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) 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 copayment for SNF care provided from June 1, 2020, to June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a treadmill. 
 
You asked the Plan to pre-approve a treadmill. You say that you need this because you are recovering from a 
heart attack. The Plan denied your request. The Plan says that exercise equipment is not covered because it is 
not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a treadmill.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid stimulating hormone (TSH) testing rendered on 
July 24, 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 screening tests are not covered. 
 
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, TSH testing, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
thyroid stimulating hormone (TSH) testing rendered on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on 
September 15, 2020. 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the 
charges because they are twice as high as previous injections. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct 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 20% 
coinsurance for Medicare Part B prescription drugs.  
You received a Medicare Part B drug provided on September 15, 2020. The total allowed amount is $1,222 and 
20% of that is $244.40.  
You have been asked to pay the total coinsurance amount of $244.44 for a Medicare Part B drug. A Medicare 
Part B drug 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 coinsurance for a Medicare Part B drug provided on September 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that this request exceeds your needs. 
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 pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ultrasounds provided on August 21, 2020. 
 
You asked the Plan to waive the copayments for ultrasounds. You say that you used to pay $60 and disagree 
with the increase in charges. The Plan denied your request. The Plan says the claims were processed correctly, 
and you are being charged the correct 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 $110 
copayment for each radiological diagnostic service. 
 
You received two ultrasounds on August 21, 2020. Therefore, you are responsible to pay a $110 copayment per 
each ultrasound. The total amount you owe is $220.  
 
You have been asked to pay the total copayment amount of $220 for ultrasounds. Ultrasounds fall within the 
outpatient diagnostic tests and therapeutic services and supplies 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 ultrasounds provided on August 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services provided on July 15, 2020. 
 
You asked the Plan to pay for the services provided. You say that the testing was reasonable and necessary for 
the management of the enrollee's advanced cancer. The Plan denied your request. The Plan says the genetic 
testing was not ordered by the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the testing at issue is not supported in the medical record. Specifically, the records do not indicate 
the testing was ordered by the physician who is treating the enrollee. 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 pay 
for the testing services provided on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99222) provided on August 6, 2019. 
 
You asked the Plan to pay for initial hospital care. You say that these medically necessary services were 
provided to the enrollee in good faith and that you are entitled to reimbursement for the services rendered. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for initial hospital care was not filed until September 18, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for initial hospital care (99222) provided on August 6, 2019.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
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 pre-approve SNF care. Our reviewer says that the 
documentation supports that the requested SNF coverage is medically reasonable and necessary. Our physician 
reviewer found the enrollee is currently in an inpatient rehabilitation facility (IRF). The enrollee required 
minimal assistance to stand up and to sit down. The Plan argues that the enrollee is receiving appropriate care 
at the current IRF and that she can remain there, if approved by the health plan. In stating that the enrollee is 
appropriate for a higher level of care (IRF), the health plan is effectively stating that the enrollee is appropriate 
for a lower level of care (SNF). Therefore, the enrollee meets criteria for the requested SNF coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatry services provided on May 16, 2019. 
 
You asked the Plan to pay for psychiatry services. You say that you did not receive proper notice of the 
enrollee's benefit determination. The Plan denied your request. The Plan says the claim was untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for psychiatry services was not filed until September 14, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for psychiatry services provided on May 16, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay forshoulder surgery and inpatient physician care provided to the enrollee from July 6, 2020 to July 9, 2020.You asked the Plan to pay forthis service. The Plan deniedyour request. The Plan says the enrollee did not have prior authorization. We overturned the Plans denial stating the surgery was medically necessary. The Plan requested a reopen and stated that the issue was not medical necessity but that this was a non-emergent planned surgical event and inpatient stay for which the enrollee would have needed prior authorization.The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that unless the treatment is an emergency, prior authorization is required for inpatient caser. The enrollee had a planned surgical procedure out of network that included inpatient care. The enrollee did not have prior authorization for this procedure or inpatient stay. Therefore, we decided that the Plan does not have to pay forshoulder surgery and inpatient physician care provided to the enrollee from July 6, 2020 to July 9, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lens polarization provided on September 16, 2020.

You asked the Plan to pay for the lens polarization. You say that you did not get a mirror coating, just a pair of sunglasses. The Plan denied your request. The Plan says that the polarized lenses are not a covered benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover lens upgrades.

We looked at the file and the Plan's rules. The service you are requesting payment for is a lens upgrade. Based on this information, we decided that the Plan's rules for coverage of the lens polarization have not been met. Therefore, we decided that the Plan does not have to pay for the lens polarization provided on September 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on August 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 procedure code J1040 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code J1040 is injection, methylprednisolone acetate, 80 mg.

We find that CPT code J1040 is not supported in the medical record. Specifically, there is no documentation of an injection of 80 mg of methylprednisolone acetate. 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 injection rendered on August 1, 2020.