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

 
We decided that the Plan does not have to waive the coinsurance for a hyaluronan injection provided on May 
19, 2021. 
 
You asked the Plan to waive the coinsurance for a hyaluronan injection. You say that you are being charged too 
much for the injection and if you would have known it would cost $401.76 you would not have had the 
injection. You also say the doctor advised you that she could do the injection, so you did not have to see a pain 
specialist. 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 20% 
coinsurance for Part B drugs.  The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$401.76, which is 20% coinsurance for a hyaluronan injection ($2,008.80 allowed amount x 20% coinsurance = 
$401.76). A hyaluronan injection falls within the Medicare Part B Prescription Drugs 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 a hyaluronan injection provided on May 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nurtec. 
 
You asked the Plan to pre-approve Nurtec. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare 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 Nurtec.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Infed (iron dextran) 
and Venofer (iron sucrose). 
 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 Feraheme. 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 1, 2021, 
through September 30, 2021. 
 
  You asked the Plan to pay for home health services. You say that the electronic version of the claim submitted 
shows CBSA code and value were on claim when uploaded. You say that a copy of the original claim is 
attached, and the claim should be reviewed for payment adjustment The Plan denied your request. The Plan 
says payment is not allowed for this claim because the core based statistical area/metropolitan statistical area 
(CBSA/MSA) code was missing or invalid. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for home health services provided from September 1, 2021, 
through September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis provided on January 11, 2022. 
 
You asked the Plan to pay for the orthosis. You say that the billed claim is payable. The Plan denied your 
request. The Plan says a more specific code is available. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 In this case, the CPT Code Manual definition of code L1690 is Combination, bilateral, lumbo-sacral, hip, femur 
orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment. 
 
We find that CPT code L1690 was billed with diagnosis codes M16.11 and M16.12, indicating unilateral 
primary osteoarthritis of the right and left hip, respectively. There is a more appropriate diagnosis code that 
indicates bilateral osteoarthritis of the hip. Based on this information, we decided that Medicare rules for 
coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the hip 
orthosis provided on January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral nutrition. 
 
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 not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that enteral nutrition is covered when specific criteria 
are met. 
 
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 records do not show that the 
enrollee has full or partial non-function or disease of the structures that normally permit food to reach the small 
bowel or disease that impairs digestion and/or absorption of oral diet by the small bowel. The criteria for 
coverage are not met and the enteral nutrition is therefore 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 enteral nutrition.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72110 billed for date of service January 26, 
2022. 
 You asked the Plan to pay for procedure code 72110. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 72110 is bundled into payment for 
code 72082. 
 
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 have confirmed that code 72110 
is a column II code to column I code 72082. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 72110 billed for date of service January 26, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomic testing provided on November 8, 
2021. 
 
You asked the Plan to pay for the pharmacogenomic testing. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says this testing was not ordered by the 
enrollee's treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pharmacogenomic testing have not been met. Specifically, the record indicates that this testing 
was not ordered by the enrollee's treating provider. Additionally, the documentation does not show that the 
pharmacogenomic testing was ordered due to any signs/symptoms of a drug reaction. There is no evidence that 
the testing was provided for therapeutic decision-making regarding the need for the use of any specific drug. Therefore, we decided that the Plan does not have to pay for the pharmacogenomic testing provided on 
November 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
30, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 30, 
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided 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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 patient was admitted for a subdural 
hematoma after a syncopal fall, COVID-19 infection without respiratory failure, and an abdominal mass. The 
enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF care. 
 
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 for the enrollee.
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 member is receiving appropriate in-patient acute care and 
is currently unstable for transfer to an LTACH. 
 
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 
was admitted following a fall and aspiration. The record indicates that the enrollee developed acute chronic 
hypoxic respiratory failure and although she is improving still requires acute care services. The enrollee 
continues to receive acute care services and these have not been denied. The medical record does not indicate 
that the enrollee requires services that she is not currently receiving but that would be available at the LTACH 
facility. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (93922) provided on 
December 7, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. 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 $110 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 You have been asked to pay a $107.15 copayment for an ultrasound, which is less than the standard $110. 
Ultrasounds 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 an ultrasound (93922) provided on December 
7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on November 15, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that the nursing home was responsible for 
obtaining prior authorization. The Plan denied your request. The Plan says the services were provided out-of-
network and were not 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 home health services provided on November 15, 
2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is medically necessary. 
The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have end-stage renal disease on 
hemodialysis, liver cirrhosis with ascites and pleural effusions requiring a PleurX catheter, and severe 
pulmonary hypertension with RV overload.  Hospital ABG showed acute hypercarbic resp failure, related in 
part to malfunction of the pleural catheter. You do not have a diagnosis for which Medicare covers a ventilator: 
COPD, neuromuscular disease, thoracic restrictive disease.  There is no documentation of chronic CO2 
retention when stable, and when pleural effusions are treated. You may benefit from pap therapy at home if 
OSA is confirmed on sleep testing. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and chiropractic manipulation services 
provided on August 31, 2021, to December 16, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and chiropractic manipulation services. You say that you have a 
need to go to this provider because of his easy access from your home, and the appointments he gives you. You 
also say that your son works and takes you to your appointments making it possible to not miss any. The Plan 
denied your request. The Plan says the rendering provider is not contracted by the Plan, and the member did not 
request prior authorization to received services from the non-contracted 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 and chiropractic manipulation 
services provided on August 31, 2021, to December 16, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve epidural steroid injections (664484, 64483). 
 
You asked the Plan to pre-approve the injections. You say that the enrollee does not have cauda equina 
syndrome. You say that the enrollee does have stenosis and nerve root impingement. You also say that this 
should be approved. The Plan denied your request. The Plan says that epidural steroid injections are not 
covered when the cauda equina neural structures are compressed. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation indicates disc disease is present which extends into the spinal canal 
displacing spinal roots. The reviewer found that the enrollee does not have cauda equina syndrome or other red 
flags. Therefore, the reviewer found that the requested epidural steroid injection is medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections have been met. Therefore, we decided that the Plan has to pre-
approve epidural steroid injections (664484, 64483).  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.