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

 
We decided that the Plan does not have to pay for the injections rendered on November 29, 2021. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for code 62320 to be covered, certain 
documentation requirements must be met. The documentation must include the legible signature of the 
physician or non-physician practitioner responsible for providing the care to the patient.  In addition, the 
procedure report should clearly document the indications and the medical necessity for the blocks along with 
the pre and post percent pain relief achieved immediately post-injection. 
 
The medical records in this case do not meet Medicare's documentation requirements.  Specifically, the record 
is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay 
for the injections rendered on November 29, 2021.
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 you need rehab to stay in control of your disease. 
The Plan denied your request. The Plan says your therapy needs can be met at a lower level of care. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for fractures of ribs, fibula, and foot after a fall from a balcony. 
Your medical problems are stable. You do not require treatment by multiple therapies in an intensive 
rehabilitation therapy program. While you have 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: 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 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. While the 
enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) provided by an out-of-network 
provider on January 17, 2022. 
 
You asked the Plan to pay for an extraction. You say that you are allowed to have two extractions a year. The 
Plan denied your request. The Plan says the rendered dental work is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pay for an 
extraction (D7210) provided by an out-of-network provider on January 17, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus. 
 
You asked the Plan to pre-approve Ocrevus. You say that Ocrevus is the most appropriate treatment for the 
enrollee. 
 The Plan denied your request. The Plan says the enrollee has not tried and failed Kesimpta. 
 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 Ocrevus. Our physician reviewer found 
that the enrollee has a diagnosis of relapsing remitting multiple sclerosis. The Plan requires a trial of Kesimpta 
before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. 
There is no documentation provided indicating that the Plans required drug would likely be less effective or 
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 Ocrevus have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ocrevus.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0230) provided by a participating 
provider on February 23, 2022. 
 
You asked the Plan to pay for intraoral imaging. You say that these services should be covered. The Plan 
denied your request. The Plan says the benefit limit for D0230 has already been met and exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers one intraoral 
image a year. 
 
We looked at the file and Medicare rules. Evidence was provided to show that 5 intraoral images were provided 
on February 23, 2022. One intraoral image has been approved and paid, leaving four intraoral images being 
correctly denied. Based on this information, we decided that the Plan's rules for coverage of intraoral imaging have not been met. Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0230) 
provided by a participating provider on February 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided on January 
24, 2022. 
 
You asked the Plan to pay for the hot or cold packs therapy (97010). You say that the claim was denied due to 
no authorization but you have authorization on file for this date of service. The Plan denied your request. The 
Plan says CPT codes 97530, 97110 and G0283 were overturned. The Plan also says that CPT code 97010 
remains denied as bundled services are not eligible for separate reimbursement.  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 CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the hot or cold packs therapy (97010) have not been met. Therefore, we decided that the Plan does not have 
to pay for the hot or cold packs therapy (97010) provided on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
January 13, 2022. 
 
You asked the Plan to pay for dental services. You say that your coverage changed, and you were unaware. The 
Plan denied your request. The Plan says services provided out-of-network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers covered 
dental services when the services are provided by a participating provider.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve chiropractic services. You say that you are in a lot of pain. The Plan denied 
your request. The Plan says there is no documented subluxation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
We looked at the file and the rules. The records show the services at issue were ordered due to left flank pain. 
The records do not indicate the services are for manual manipulation of the spine to correct subluxation. Based 
on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pre-approve chiropractic services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of why the preferred drugs would be contraindicated. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the Plan requires a trial 
of Rituxan, Ruxience, or Riabni before they will approve the requested drug. In this case, the patient has not 
tried and failed the required drugs. 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. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information submitted does not meet the plan's medical necessity guidelines for 
coverage. 
 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the Plan requires a trial 
of drug Infed (iron dextran) and Venofer (iron sucrose) before they will approve the requested drug. In this 
case, the patient has not tried and failed the required drugs. 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. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections rendered on December 6, 2021. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for code 62320 to be covered, certain 
documentation requirements must be met. The documentation must include the legible signature of the 
physician or non-physician practitioner responsible for providing the care to the patient.  In addition, the 
procedure report should clearly document the indications and the medical necessity for the blocks along with 
the pre and post percent pain relief achieved immediately post-injection. 
 
The medical records in this case do not meet Medicare's documentation requirements.  Specifically, the record 
is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay 
for the injections rendered on December 6, 2021.
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 enrollee does not meet the Medicare criteria for admission to an Inpatient 
Rehabilitation Facility (IRF). 
 
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 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 respiratory heart failure, congestive heart failure, and chronic obstructive pulmonary diseease 
(COPD) exacerbation. 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, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you are worried your cancer is spreading. The 
Plan denied your request. The Plan says your group has in-network providers. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
oncology services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract surgery (66984) provided on 
September 1, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $350 per 
day for outpatient procedures and services, including, but not limited to, outpatient surgery performed in an 
outpatient hospital or ambulatory surgical center.  
 You have been asked to pay $350 for the outpatient surgery provided. 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 cataract surgery (66984) provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 22, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
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 an epidural injection provided on 
November 22, 2021 have been met. The Health Plan has not received the required clinical records to support 
the medical necessity of the service for the date of service requested. Therefore, we decided that the Plan does 
not have to pay for an epidural injection provided on November 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Methylphenid tablet 10mg. 
 
You asked the Plan to pay for the drug. You say that this is medically necessary. The Plan denied your request. 
The Plan says this self-administered drug does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for Methylphenid tablet 10mg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
requested service is not covered. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for 
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial 
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment 
with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days. 
 
We looked at the file and the rules. In this case, nonunion of a long bone fracture is not considered to exist 
under Medicare rules. Based on this information, we decided that the Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a bone growth stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hematology/oncology services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you would like to continue treatment with this 
provider. The Plan denied your request. The Plan says you are not receiving an active course of treatment. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
hematology/oncology services to be provided by an out-of-network (OON) provider.