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

 
We decided that the Plan does not have to pre-approve interpreter services for a medical appointment. 
 
You asked the Plan to pre-approve interpreter services. You say that it is necessary for you to have a translator. 
The Plan denied your request. The Plan says the provider has offered an electronic translation option. 
 
The Plan must follow Medicare rules. Medicare rules say that health care professionals must provide 
information regarding treatment options in a culturally-competent manner. 
 
We looked at the file and Medicare rules. In this case, the Plan has confirmed that translation services that 
satisfy Medicare coverage rules will be provided. Based on this information, we decided that Medicare rules 
for coverage of interpreter services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve interpreter services for a medical appointment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine physical exam (code 99397) you had on 
September 20, 2021. 
 
You asked the Plan to pay for the physical exam. You say that you are entitled to a yearly physical, so this 
should be covered. The Plan denied your request. The Plan says annual physicals are not covered under your 
Plan benefits. 
 
The Plan follows Medicare rules. The rules explicitly say that routine physical exams are not covered. You are 
covered for an Annual Wellness Visit. However, an Annual Wellness Visit is not the same thing as a routine 
physical.  An Annual Wellness visit is limited to a visit done only to develop or update a personalized 
prevention plan based on your current health and risk factors. We looked at the medical records from the visit 
in question. The records clearly state the visit you had was a routine physical, not an Annual Wellness Visit. In 
addition, Annual Wellness Visits are coded using one of two procedure codes: G0438 or G0439.  Your doctor 
did not bill using either of these codes.  Finally, you also signed an Advanced Beneficiary Notice when you had 
this visit, indicating that you were advised that this visit was not covered by Medicare or your Plan. Therefore, 
we decided that the Plan does not have to pay for the routine physical exam (code 99397) you had on 
September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PureWick urine catheter system. 
 
You asked the Plan to pre-approve the service. You say that the last time you were hospitalized they used a PureWick catheter on you 
and it was the only thing that helped. The Plan denied your request. The Plan says the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pre-approve the service. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the record indicates that you have stress incontinence. 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. The elements of the coverage criteria are not satisfied. The requested service is not recommended 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve PureWick urine catheter 
system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CT, thorax, diagnostic; without contrast material 
(CPT code 71250). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your 
request. The Plan says they did not receive physical exam results that show a reason this study is needed. The 
Plan states the enrollee's records did not include a detailed history that shows this study is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our physician reviewer 
found the review has determined that the requested CT scan is not medically reasonable and necessary. We 
looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CT, thorax, diagnostic; without contrast material (CPT code 71250).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coronary artery bypass, using arterial graft(s); single 
arterial graft (CPT code 33533), replacement, aortic valve, open, with cardiopulmonary bypass; with prosthetic 
valve other than homograft or stentless valve (CPT code 33405) and the inpatient hospital care. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has this surgery scheduled June 7th 
and if this does not get approved the enrollee will be at risk for seizure, stroke, heart attack, and possible death. 
The Plan denied your request. The Plan says the enrollee's request is not medically necessary because their 
records do not show that they have significant heart vessel blockage, narrowing of the aortic valve, or severe 
aortic regurgitation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the most recent cardiac evaluation showed moderate-severe aortic regurgitation with little or no aortic stenosis, with minimal left ventricle (LV) dilatation and normal ventricular function. There is no 
documentation of significant coronary artery stenosis necessitating coronary artery bypass graft surgery 
(CABG) surgery. As a result, at this time the requested surgical aortic valve replacement (SAVR) and CABG 
would not be considered medically necessary in this enrollee's clinical management based on the submitted 
documentation. Furthermore, the surgical services and the inpatient hospital care are not necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve coronary artery bypass, using arterial graft(s); single arterial graft (CPT code 33533), 
replacement, aortic valve, open, with cardiopulmonary bypass; with prosthetic valve other than homograft or 
stentless valve (CPT code 33405) and the inpatient hospital care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional physical therapy visits (CPT code 
97164). 
 
You asked the Plan to pre-approve the physical therapy visits. You say that the enrollee is showing 
improvement with therapy. The Plan denied your request. The Plan says the services are not 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 the 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 the documentation does not support the need for 8 
additional Physical therapy visits which are not medically necessary for coverage. The enrollee has improved 
with skilled therapy as per physical therapy (PT) documentation and continued therapy is repetitive. The 
physical therapy visits are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve eight (8) additional physical therapy visits (CPT code 97164).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the visits you had with a cardiologist 
while you were in the hospital from September 25, 2021, to September 30, 2021. 
 
You asked the Plan to waive the copayments for the cardiology visits. You say that you were an inpatient in the 
hospital, so you should not have these copayments for physician services. The Plan denied your request. The 
Plan says you were charged these copayments 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 a $25 
copayment for specialist services, including services in a hospital outpatient department.   
You have been asked to pay a $25 copayment for each of the cardiology visits. We looked at the case file 
documentation and it shows that you were not admitted to the hospital as an inpatient.  Rather, you were kept in 
the hospital in observation status, which is considered an outpatient status.  Your Evidence of Coverage clearly 
says that you can be in outpatient observation status even if you stay in the hospital overnight.  Because you 
were in an outpatient hospital status, separate cost sharing for physician services can apply.  Your Evidence of 
Coverage says that you pay a $25 copayment for each specialist service, including services in a hospital 
outpatient department. 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 visits you had with a 
cardiologist while you were in the hospital from September 25, 2021, to September 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services provided on 
December 8, 2021, and December 9, 2021 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you never went to the 
hospital for your tests. The Plan denied your request. The Plan says the copayment was 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 a $25 
copayment for basic radiological services performed at an in-network outpatient hospital and a $200 
copayment for advanced imaging services rendered at an in-network outpatient hospital.  
You have been asked to pay a total of $205 for the outpatient hospital services.  
 
Date of Service Service Allowed Amount Standard 
Copayment 
Member Liability 
December 8, 2021 Echo w/ Doppler $419.21 $25 $25 
December 9, 2021 X-ray $70.23 $25 $25 
December 9, 2021 CT Scan $155 $200 $155 
Total 
   
$205 
 
Outpatient hospital services fall within the Outpatient hospital 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 copayment for outpatient hospital services provided on December 8, 2021, and 
December 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the enrollee has used all twelve (12) trips. 
 
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 Plans coverage rules apply in this 
case. We looked at your request, the records in the case file, and the rules. The request exceeds the enrollee's 
benefit limit. The enrollee's 2022 EOC states the enrollee has twelve (12) trips every year. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have any 
parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without 
any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline. Although 
further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled 
services can be provided at a lower level of care than a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve the medication. You say that you are requesting to prescribe Reblozyl as the 
enrollee is losing their response to current myelodysplastic syndrome treatment and has become transfusion 
dependent. The Plan denied your request. The Plan says the medication is not necessary. 
 
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 the medication. Our physician reviewer 
found the review has determined that the documentation did not support that the Reblozyl is medically 
reasonable and necessary for the enrollee. The documentation did not support that the Reblozyl is safe and 
effective for the 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Reblozyl.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the documentation does not show that the enrollee has tried or cannot use 
Orthovisc or Supartz FX (step therapy requirement). 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the case file does not contain documentation of trial and failure of Orthovisc or Supartz FX. The 
documentation does not support that Orthovisc or Supartz FX 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc (CPT code J7327). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do not have a record from the enrollee's prescriber that shows they have tried 
one of the preferred drugs (Orthovisc, Synvisc or Synvisc One), or that they have medical reasons that prevent 
the enrollee from using one of them. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the enrollee has not tried and failed the required drug(s): Orthovisc, Synvisc or Synvisc One. The 
documentation does not support that Monovisc (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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monovisc (CPT code J7327).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for optic nerve imaging provided on October 
29, 2021. 
 
You asked the Plan to waive the copayment for optic nerve imaging. You say that neither the insurance 
representative nor the provider could give you a satisfactory explanation of this charge. 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 $50 
copayment for diagnostic testing.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $39.46, which is less than the $50 copayment for optic nerve imaging. Optic nerve imaging falls 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 copayment for optic nerve imaging provided on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix, per square centimeter (CPT code Q4186 x10). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Epifix treatment is appropriate for certain wounds on the lower extremities (legs and 
feet). The Plan states per UpToDate and industry standards, Epifix treatment is appropriate for diabetic foot 
ulcers. The Plan states based on the submitted documentation the enrollee's wound is not on their legs or feet; 
therefore, the request for Epifix does not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our physician reviewer 
found the documentation describes improvement of the wound with current treatment with good tolerance of 
current treatment, there was insufficient support made for Epifix at this time. Therefore, this request for such 
will be considered not medically 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Epifix, per square centimeter (CPT code Q4186 x10).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refill kit for an implantable infusion pump (code A4220), 
the morphine sulfate (code J2274), and the miscellaneous infusion drug (code J3490) you billed for date of 
service August 18, 2021. 
 
You asked the Plan to pay for the infusion supplies and drugs. You did not provide a specific argument with 
your appeal request. The Plan denied your request. The Plan says despite multiple requests, you have not 
provided proof of delivery of these items. 
 
The Plan must follow Medicare rules. Medicare rules say that suppliers must maintain proof of delivery 
documentation. Compliance with proof of delivery may be required as a condition of payment and must be 
made available as requested. The Plan has requested this proof of delivery information from you several times 
and to date, this information has not been provided.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infusion supplies and drugs have not been met. Therefore, we decided that the Plan does not 
have to pay for the refill kit for an implantable infusion pump (code A4220), the morphine sulfate (code 
J2274), and the miscellaneous infusion drug (code J3490) you billed for date of service August 18, 2021.