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

 
We decided that the Plan does not have to reimburse you for the At-Home coronavirus test purchased on 
November 8, 2021. 
 
You asked the Plan to reimburse you for the At-Home coronavirus test. You say that you were exposed to a 
person with the coronavirus. You say that you took an At-Home coronavirus test to minimize further exposure 
to others around you. You also say that you should be reimbursed for the amount you paid. The Plan denied 
your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. CMS says that plans or issuers may, but are not required by federal law 
to, provide such coverage for at-home over-the-counter COVID-19 tests purchased before January 15, 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the At-Home coronavirus test have not been met. Specifically, the At-Home coronavirus test was 
purchased prior to January 15, 2022. Therefore, we decided that the Plan does not have to reimburse you for 
the At-Home coronavirus test purchased on November 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of radiofrequency ablation to the sacroiliac joint in 
the setting of chronic low back pain have not been demonstrated in the peer-reviewed literature. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental/investigational procedure because of the wide variation in efficacy 
published in the peer reviewed literature. Therefore, the request is deemed not medically reasonable or 
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 sacroiliac joint radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider 
on November 12, 2021. 
 
You asked the Plan to pay for the services. You say that you were not told that this was a non-participating 
provider. The Plan denied your request. The Plan says the services were not authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services.  Therefore, we decided that the Plan does not have to pay for the services provided to you by an out-of-network 
provider on November 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says the requested drug is not medically necessary as the enrollee has not completed 3 
months of conservative non-medication treatment. 
 
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 Hyalgan. Our reviewer says that the 
requested drug is not medically necessary and reasonable for the enrollee. Our physician reviewer found that 
the enrollee is a 71-year-old female with a history of bilateral knee pain due to osteoarthritis. She rated her pain 
as 10/10. Ultrasound and X-rays demonstrate bone on bone arthritis. She had a physical therapy evaluation and 
was provided a knee brace on March 2, 2022.  Her provider has recommended viscosupplementation therapy 
with Hyalgan. 
 
Intra-articular injections with hyaluronic acid (Hyalgan) are recommended as a possible option for severe 
osteoarthritis for patients who have not responded adequately to recommended conservative treatments 
(exercise, Non-steroidal anti-inflammatory drugs, and/or Acetaminophen) to potentially delay total knee 
replacement. 
 
In this case, the member has not completed 3 months of conservative non-medication treatment.  The review has determined that the documentation does not support that Hyalgan is medically reasonable or necessary for 
this patient. The documentation does not support that Hyalgan is safe and effective for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving the care she needs in the hospital 
where she is now and there is no need to transfer to the LTACH at this time. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for LTACH services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a short-latency somatosensory evoked potential study 
(95938) and visual evoked potential (95930) provided August 25, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that please review attachments and process for 
payment. The Plan denied your request. The Plan says there evidence of misrepresented services. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we find that CPT codes 95930 and 95938 is not supported in the medical record. Specifically, there 
is no signed physician order and claims history shows no relationship between the ordering provider and the 
enrollee. There are no authenticated medical records from the ordering provider documenting the treating 
physician had intended the clinical diagnostic test be performed. Based on this information, we decided that 
Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan 
does not have to pay for a short-latency somatosensory evoked potential study (95938) and visual evoked 
potential (95930) provided August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on June 14, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you believe in treating your patients medical needs 
first, and this treatment was medically necessary. The Plan denied your request. The Plan says the rendering 
provider is a non-participating provider and there is no referring provider involved in these services. The Plan 
also says they did not authorize any services for this provider. 
 
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 (99213) provided on June 14, 2021, 
by an out-of-network (OON) provider.
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 enrollee needs aggressive therapy to get back to 
an independent level. You say that all other levels of care refuse to accept a patient with a sex offender status. 
You say that the enrollee is fully dependent, is at max assist levels, and cannot walk. The Plan denied your 
request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the 
enrollee can safely receive the services needed 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 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. surgical repair of a hip fracture/dislocation after a fall. The enrollee's 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patient lift to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a patient lift. You say that this is necessary for you. The Plan denied your 
request. The Plan says that there are network providers that can provide this service. 
 
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 
a patient lift to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 22, 2020. 
 
You asked the Plan to pay for ambulance services. You say that you identified the address was incorrect and 
the claim was resubmitted on July 28, 2021. The Plan denied your request. The Plan says the claim was filed 
beyond the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for ambulance services was not filed until June 15, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for ambulance services provided on February 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided from November 16, 2021, 
to November 18, 2021. 
 
You asked the Plan to pay for the services. You say that you should not have to pay for these services. The Plan 
denied your request. The Plan says these services are not covered. 
 
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.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services provided from November 16, 2021, to 
November 18, 2021.
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 these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She 
has not tried and failed the Plan's required drugs, Orthovisc, Synvisc, or Synvisc-One. The records do not show 
that the required drugs would be contraindicated or less effective; therefore, Euflexxa is not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 pre-approve Methotrexate for the 
enrollee.  
 Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea for the enrollee. 
 
You asked the Plan to pre-approve Eylea. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no documentation indicating that the preferred product is not clinically 
appropriate. 
 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 Eylea. Our reviewer says that Eylea is 
not medically reasonable and necessary for the enrollee. The Plan requires a trial of Avastin before they will 
approve Eylea. In this case, the patient has not tried and failed the required drug. There is no documentation 
indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the 
enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for 
Eylea. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care visit provided by an in-
network provider on November 14, 2021. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that you were not informed that 
your copayment would be different at the urgent care center than what it would have been at your primary care 
physician's office. The Plan denied your request. The Plan says you have been asked to pay 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 $45 
copayment for each covered office visit to other providers for urgently needed services.  
 You have been asked to pay a $45 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently needed 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 reduce the copayment for the urgent 
care visit provided by an in-network provider on November 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option 
and accessories. 
 
You asked the Plan to pre-approve group 3 power wheelchair with single power option and accessories. You 
say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the 
requested wheelchair exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with single power option 
is subject to the criteria listed 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 group 3 power wheelchair with single 
power option and accessories. Our reviewer says that the requested power wheelchair is not medically 
reasonable and necessary. Our physician reviewer found that the requested Group 3 power wheelchair with 
accessories is not medically necessary per the Local Coverage Determination (LCD) Power Mobility Devices 
(L33789). The patient has a Group 3 qualifying diagnosis. The documentation indicates the patient has a 
mobility deficit that impairs MRADLs in the home. The documentation indicates that the patient is unable to 
use a walker, manual wheelchair or cane due to weakness and balances issues. The documentation does not 
reveal that the patient uses a ventilator attached to a wheelchair, is unable to perform a functional weight shift 
as he can independently pivot transfer. There is no evidence of intermittent catheterization.  The physician 
documentation does not indicate objective evidence of spasticity on a BLE physical exam that needs a power 
seating system for management therefore the request for power tilt and recline exceeds the patient's medical 
needs. The tilt and recline exceeds the patient's medical needs therefore the Group 3 power wheelchair with 
single power option (K0856, E2363) and accessories is not medically necessary and Power Tilt recline (E1002, 
E1012) is 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 group 3 power wheelchair with single power option and accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with 
single power option and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 17, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on July 17, 2020.