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

 
We decided that the Plan does not have to pre-approve Barostim. 
 
You asked the Plan to pre-approve Barostim. You say that the requested Barostim is medically necessary. The 
Plan denied your request. The Plan says the requested Barostim is 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 Barostim. Our reviewer says that the 
requested Barostim is not medically necessary. Our physician reviewer found Baroreflex stimulation devices 
have been considered potential alternative treatments for resistant hypertension and heart failure. The Barostim 
Neo system is an electronic pulse generator implanted underneath the clavicle with a lead tunneled under the 
skin to the carotid sinus in the neck. The pulse generator delivers electrical impulses, analogous to a cardiac 
pacemaker, to the baroreceptors of one of the carotid arteries. In August 2019 the Food and Drug 
Administration (FDA) approved the system for use in patients with refractory heart failure who remain 
symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III, have an ejection 
fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in normal daily activities, distance walked, quality of life, and improved cardiac 
levels biomarker levels. There remains an absence of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the 
Barostim Neo system would not be considered medically reasonable and necessary in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Barostim have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Barostim.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent antigen detection by immunoassay with 
direct optical observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 
 
You asked the Plan to pay for infectious agent antigen detection by immunoassay with direct optical 
observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). You say that you had medical 
issues and the test was to rule out COVID-19. The Plan denied your request. The Plan says this service is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of infectious agent antigen detection by 
immunoassay with direct optical observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 
(Coronavirus disease) have been met. There are no medical records to determine why this COVID-19 testing 
was performed and if it was done for Medicare-covered purposes. Therefore, we decided that the Plan does not 
have to pay for infectious agent antigen detection by immunoassay with direct optical observation; severe acute 
respiratory syndrome coronavirus 2 (SARS-CoV-2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy provided on November 9, 
2021. 
 
You asked the Plan to waive the copayment for endoscopy. You say that you would like the copayment 
reviewed because you cannot afford to pay this bill. The Plan denied your request. The Plan says copayment 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 $350 
copayment for each Medicare-covered outpatient surgery at an in-network hospital outpatient facility.  
 
  You have been asked to pay $350 copayment for endoscopy. The endoscopy 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 endoscopy provided on November 9, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency care (ER) visit provided on 
November 18, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $65 
copayment for Emergency care.  
 
 
  You have been asked to pay a $65 copayment for an ER visit. 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 emergency care (ER) visit provided on November 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan on 
November 23, 2021. 
 
You asked the Plan to waive the copayment for a Computed Tomography (CT) scan. You say that that the plan 
should pay the full allowed cost under Medicare. The Plan denied your request. The Plan says the cost share 
applied 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 $160 
copayment for a Computed Tomography (CT) scan. The member is responsible for a copayment of $160.00 for 
every radiological diagnostic service. The allowed amount is $127.42, which is less than the copayment 
amount and therefore the member will only be liable for the allowed amount. 
 You have been asked to pay a $160 copayment for a Computed Tomography (CT) scan. Computed 
Tomography (CT) scans 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 copayment for a Computed Tomography (CT) 
scan on November 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 1, 
2022 to January 3, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were transported to 
a hospital where you had to undergo minor surgery. You say that you were covered by financial medical aid 
and do not have to pay any copayments. The Plan denied your request. The Plan says you have been charged 
the correct copayment 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 $200 
copayment for per day for days 1-5 of a hospital stay.  
 
 
 
 You have been asked to pay a $200 copayment for an inpatient hospital stay. 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 January 1, 2022 to January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services (98941, 99204, 72100, 72040) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve chiropractic services. You say that you should be considered a network 
provider. The Plan denied your request. The Plan says this service is available 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 
chiropractic services (98941, 99204, 72100, 72040) 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 telehealth visit on November 24, 2021. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that you do not think there should be a 
charge for a telehealth visit. The Plan denied your request. The Plan says copayment 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 $30 
copayment for each specialist telehealth visit.  
 
  You have been asked to pay $30 copayment for telehealth visit. The telehealth visit falls within the 
Physician/Practitioner services, including doctors office visits and Telehealth Services benefit categories. 
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 telehealth visit on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit and transitional care 
management services provided on July 6, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit and transitional care management services. You 
say that since the member was in a nursing facility, the doctor was not responsible to get authorization, and the 
nursing home is responsible to obtain prior authorization for their patients. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to the services 
being rendered. 
 
 
 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 had network providers 
available who could have provided 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 a domiciliary or rest home visit and transitional 
care management services provided on July 6, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing services provided on September 7, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory testing services. You say that you do not have direct access or 
interaction with patients prior to performing the laboratory testing, and you  have included the statement of 
medical necessity that is signed by the ordering physician on the bottom of the test form. The Plan denied your 
request. The Plan says this provider is not a network provider with the Plan, and they have also determined that 
these services are not urgent or emergent, nor were they 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 had network providers 
available who could have provided 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 testing services provided on September 
7, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 29, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
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 had network providers 
available who could have provided 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 an office visit provided on September 29, 2021 by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane (J9264). 
 
You asked the Plan to pre-approve Abraxane. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not tried and failed the preferred drugs, Taxol or Taxotere. 
 
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 Abraxane. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Abraxane (J9264).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laboratory services (CPT code(s): 81479, 81194, 
81301, 81455). 
 
You asked the Plan to pre-approve the laboratory services. You say that you have suspected that this mole 
could be cancer related. The Plan denied your request. The Plan says there are no notes from your physician. 
The Plan states they contacted your provider's office for records, but they did not send the Plan any records or 
information supporting this laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services (CPT code(s): 
81479, 81194, 81301, 81455) have been met. Medical records were not provided to support that this testing is 
necessary. Therefore, we decided that the Plan does not have to pre-approve the laboratory services (CPT 
code(s): 81479, 81194, 81301, 81455).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on October 20, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the physician services. You say that the facility did not obtain the proper 
authorization and it was medically necessary to provide treatment to the enrollee. The Plan denied your request. 
The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 had network providers 
available who could have provided 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 physician services provided on October 20, 
2021, by an OON provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed one of the preferred 
drugs, Retacrit or Procrit. 
 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 Aranesp. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the required drugs. The reviewer found that there is no 
documentation provided indicating that the plans required drugs would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Myocardial imaging, positron emission tomography 
(PET) study. 
 
You asked the Plan to pre-approve a Myocardial imaging, positron emission tomography (PET) study. You say 
that the requested Myocardial imaging, PET study is medically necessary. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for the requested Myocardial imaging, positron emission 
tomography (PET) study. 
 
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 Myocardial imaging, positron 
emission tomography (PET) study. Our reviewer says that the enrollee does not meet criteria for the requested 
Myocardial imaging, positron emission tomography (PET) study. Our physician reviewer found previous 
nuclear stress testing has already demonstrated a reversible myocardial defect. Guidelines do not support the 
use of cardiac PET imaging in this role. As a result, at this time cardiac PET scanning would not be considered 
medically reasonable and necessary in this enrollee's clinical management. 
 
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 Myocardial imaging, positron emission tomography (PET) study have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Myocardial imaging, positron 
emission tomography (PET) study.