Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a myocardial perfusion imaging (SPECT) 
test and a cardiovascular stress test provided on January 28, 2022. We also decided that the Plan does not have to waive the coinsurance for a technetium (contrast) injection and a regadenoson injection provided on January 
28, 2022. 
 
You asked the Plan to waive the copayments and coinsurance for the SPECT test, stress test, contrast injection, 
and regadenoson injection. You say that you only have retirement income and feel the copayments are too high. 
The Plan denied your request. The Plan says the correct copayments and coinsurance were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for advanced imaging services. 
 
Your contract with the Plan also clearly says that you must pay a $20 copayment for diagnostic procedures and 
tests in a specialist's office. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for medical supplies, such 
as contrast agents used in certain diagnostic procedures. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 
You have been asked to pay a $125 copayment for the SPECT test and a $20 copayment for the stress test. The 
SPECT test and stress test fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. You have also been asked to pay $44.44 for the technetium contrast, which is 20% of the 
allowed amount ($222.20 allowed amount x 20% coinsurance = $44.44). The technetium contrast also falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also 
been asked to pay $49.03 for the regadenoson injection, which is 20% of the allowed amount ($245.16 allowed 
amount x 20% coinsurance = $49.03). The regadenoson injection falls within the Medicare Part B Prescription 
Drugs benefit category. The total for all services is $238.47. 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 a myocardial perfusion imaging (SPECT) test and a cardiovascular stress test provided on January 28, 2022. 
We also decided that the Plan does not have to waive the coinsurance for a technetium (contrast) injection and 
a regadenoson injection provided on January 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a back injection performed on February 4, 
2022. 
 
You asked the Plan to waive the copayment for the injection. You say that the injection did not help and you 
should not have to pay for it. 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 $315 
copayment for surgical services at an ambulatory surgical center or outpatient hospital.  
 
You have been asked to pay a $315 copayment for the injection. The injection 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 a back injection performed on February 4, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for pelvic fracture and humerus fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment provided on January 
13, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that since you had covid this 
equipment should be covered. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay $17.51 which is 20% of the allowed amount for the oxygen equipment. The 
allowed amount is $87.52 (20% x 87.52= $17.51). Oxygen equipment falls within the Durable medical 
equipment (DME) and related 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 coinsurance 
for oxygen equipment provided on January 13, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that the requested Monovisc is medically necessary. 
The Plan denied your request. The Plan says the enrollee must try and fail Gel-One AND Synvisc/Synvisc-One 
first. 
 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 Monovisc. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Gel-
One AND Synvisc/Synvisc-One first before they will approve the requested drug. In this case, the enrollee has 
not tried and failed the required drug(s). There is no documentation provided indicating that the plans required 
drug(s) would likely be less effective and/or likely have adverse effects 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of home health services beyond June 
23, 2022. 
 
You asked the Plan to pre-approve the continuation of home health services. You say that this home health care 
continues to be medically reasonable and necessary. The Plan denied your request. The Plan says the criteria 
for the continuation of home health care have not been met. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 continuation of home health 
services. Our reviewer says that the requested home health services are not medically reasonable and necessary. 
Our physician reviewer found the enrollee is a 67-year-old male with a history of cerebrovascular accident. A 
June 9, 2022, occupational therapy evaluation indicates you are moderately independent with toilet transfers 
and shower transfers, independent with grooming, moderately independent with bathing and toileting, 
independent with dressing, and moderately independent with laundry and light cleaning. Based on the limited 
documentation provided, the Plan's denial should be upheld. You do not have documented home health 
occupational therapy needs. As such, the requested, home health services are no longer medically necessary or 
reasonable. 
 
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 continuation of home health services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continuation of home health services beyond June 23, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 15, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron. 
 
You asked the Plan to pre-approve Lupron. You say that this drug is medically reasonable and necessary for the 
enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Lupron. Our reviewer says that this 
drug is not medically reasonable and necessary. Our physician reviewer found the record indicates that the 
enrollee has prostate cancer. The requested medication is a new start. 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. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Lupron have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Lupron.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show that the enrollee needs, nor could he participate in 3 hours/day 
for 5 days a week or 15 hours per week of therapy, and the services can be provided safely 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 in the Medicare rules section. 
 
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 based on the medical records provided the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patients medical conditions are stable on intravenous vancomycin through 
06/27/2022 and otherwise on outpatient medications with no issues that require a physicians evaluation three 
or more times per week; he is reported to have "no complaints" and to be in no acute distress with a stable 
physical exam. The patient does require physical therapy and occupational therapy services, but the medical 
records provided do not clarify why the patient requires an intensive inpatient rehabilitation therapy program. 
Provided records do not explain why the intensive inpatient rehabilitation therapy program is necessary and 
why therapy at a lower level of care such as in a skilled nursing facility is not appropriate for the patient. There 
is concern that the patient will not be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility due to his documented decreased endurance. 
The records do not clarify that treatment at the skilled nursing facility level is not appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strips. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from the preferred provider. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file and Medicare rules. The requested items are from a non-preferred provider. The services 
are available from one of the Plans preferred providers. 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 
pre-approve Accu-Chek Aviva Plus test strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 12 home health physical therapy (PT) 
visits. 
 
You asked the Plan to pre-approve the additional home health PT services. You say that it is felt more PT in the 
home is required. The Plan denied your request. The Plan says this is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health PT services. 
Our reviewer says that the requested home health PT is not shown to be medically necessary in this case. Our 
physician reviewer found the enrollee does not have documented, ongoing  PT needs. The enrollee is 
functioning at a level corresponding to a lower level of care (i.e., home exercise program, outpatient therapy, 
layperson supervision). As such, the requested, ongoing, home health PT services are not medically necessary 
or reasonable. 
 
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 additional home health PT services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an additional 12 home health physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantation of a carotid sinus baroreflex activation 
device (0266T) to be provided by an out-of-network (OON) facility. 
 
You asked the Plan to pre-approve an implantation of a carotid sinus baroreflex activation device. You say that 
the requested procedure is medically necessary. The Plan denied your request. The Plan says the enrollee must 
receive care from a network provider and facility. There are in-network hospitals available for these services. 
 
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 hospital in this case is not a network facility with the Plan. The Plan has network hospitals 
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 
an implantation of a carotid sinus baroreflex activation device (0266T) to be provided by an out-of-network 
(OON) facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the power wheelchair accessories. You say that the enrollee needs a new 
chair that will support his scoliosis. The requested items are medically necessary. The Plan denied your request. 
The Plan says there is no need to control more than two power options through the joystick and a seat elevator 
does not serve a medical purpose and is never covered. 
 
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 power seat elevation system (E2300) and an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311).