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

 
We decided that the Plan does not have to waive one of the copayments for a transthoracic echocardiogram 
(TTE) with doppler and a myocardial perfusion imaging (SPECT) test provided from March 10, 2022, to 
March 11, 2022. 
 
You asked the Plan to waive one of the copayments for the TTE with doppler and SPECT test. You say that 
this was a two-day procedure that should be considered one test. 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 $20 
copayment for each advanced radiology service.  
 
You have been asked to pay a $20 copayment each for the TTE with doppler and SPECT test, for a total of 
$40. The TTE with doppler and SPECT test are two different tests performed on separate days, and 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 one of the copayments for a transthoracic echocardiogram (TTE) with doppler and a 
myocardial perfusion imaging (SPECT) test provided from March 10, 2022, to March 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Humira Pen (J0135). 
 
You asked the Plan to pre-approve Humira Pen. You say that this should be covered. 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 a Humira Pen (J0135).  
 Benefits for Humira Pen 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second electrocardiogram (ECG) provided to the enrollee 
on February 16, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records received from the provider only showed one test, and that it had been 
compared to the results of a previous test conducted on 01/15/2022. 
 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 a second electrocardiogram (ECG) 
provided to the enrollee on February 16, 2022. have been met. The provider has not sent in medical records to 
show that multiple electrocardiograms were rendered on this date of service. The record only shows one exam.. 
Therefore, we decided that the Plan does not have to pay for a second electrocardiogram (ECG) provided to the 
enrollee on February 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July 
16, 2021, to July 27, 2021. 
 
You asked the Plan to pay for the services. You say that the billed diagnosis is valid for this encounter. The 
Plan denied your request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 071 (NONSPECIFIC 
CEREBROVASCULAR DISORDERS WITH CC). 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 
pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found that the review has determined that the records do not support that use 
of G93.41 - Hematopoietic stem cell transplantation-associated thrombotic microangiopathy [HSCT-TMA] - as 
a valid secondary diagnosis. The records do not support the use of DRG 071 in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from July 16, 2021, to July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis. 
 
You asked the Plan to pre-approve Hymovis. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Hymovis. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of chronic pain with pain in unspecified knee. The documentation does not 
support that the enrollee has tried and failed Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. The 
documentation does not support that Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One would likely 
be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the enrollee 
does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hymovis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve a facet joint injection. You say that you've had severe pain for 5 years and 
were sent to pain management. The Plan denied your request. The Plan says this request is not medically 
necessary because the response to your initial facet joint procedure did not yield 80% relief of the primary pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a facet joint procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the LCD requires 80% pain relief from each set of diagnostic medial branch 
block. 80% pain relief was not achieved; therefore, the request is 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 a facet joint procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a facet joint injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Vascepa capsule. 
 
You asked the Plan to pre-approve Vascepa. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Vascepa 
capsule.  
 Benefits for Vascepa 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on March 27, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that the enrollee is 
requesting reconsideration because the claim should be covered due to neglect. The Plan denied your request. 
The Plan says the cost sharing the enrollee is being charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $90 copayment for emergency services in an emergency room. Emergency care refers to services 
that are: furnished by a provider qualified to furnish emergency services and needed to evaluate or stabilize an 
emergency medical condition. A medical emergency is when you, or any other prudent layperson with an 
average knowledge of health and medicine, believe that you have medical symptoms that require immediate 
medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms 
may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. 
 
 The enrollee has been asked to pay a $90 copayment for emergency room services. Emergency room services 
fall within the Emergency care benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
emergency room services on March 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
April 25, 2022. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you thought 
telehealth services were fully covered. 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 $45 
copayment for each specialist visit, including telehealth services.  
 
You have been asked to pay a $45 copayment for the specialist telehealth visit. The specialist telehealth visit 
falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 specialist telehealth visit provided on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection of an eye drug provided on April 7, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an injection of an eye drug. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the payment was denied for absence of 
precertification/authorization. The Plan also says that there is no referral letter from an in-network physician, 
and the services were not medically necessary. The Plan also says that there are in-network providers available. 
 
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 injection of an eye drug provided on April 7, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex lumbar interspinous decompression device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is unproven with insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. Food and Drug Administration (FDA) indications include the Coflex device is for use in one- or 
two-level lumbar stenosis from L1- L5 in skeletally mature patients with at least moderate impairment in 
function, who experience relief in flexion from their symptoms of leg/buttocks/ groin pain, with or without 
back pain, and who have undergone at least 6 months of non-operative treatment. FDA contraindications 
include prior fusion or decompressive laminectomy, radiographically compromised vertebral bodies, severe facet hypertrophy, spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately 
addressed in the medical records. There is no discussion of spinal instability on flexion/extension films. Height 
is 67.5 inches, weight is 213.6 pounds, and body mass index is 33 kg/m2. There is imaging evidence of 
scoliosis of the lumbar spine, with no documentation of the Cobb angle. There is no discussion indicating that a 
dual energy x-ray absorptiometry (DEXA) scan has demonstrated the lack of significant osteoporosis in this 
patient. There is no overall/compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the requested Coflex lumbar 
interspinous decompression device at L3-4 and L4-5, in this case, is 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Coflex lumbar interspinous decompression device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) imaging of the chest, 
abdomen, and pelvis for the enrollee. 
 
You asked the Plan to pre-approve the scans. You say that this is medically necessary. The Plan denied your 
request. The Plan says several tests were recommended, and no results of these tests were sent. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 scans. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the notes from 
7/15/22 shows that the order for computed tomography (CT) imaging was cancelled due to the enrolllee's 
refusal to have the exams. 
 
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 scans have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) imaging of the chest, abdomen, and pelvis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth facility fee provided on January 17, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth facility fee. You say that the service was medically necessary. The 
Plan denied your request. The Plan says no prior authorization was obtained. 
 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 did not pre-approve the 
telehealth facility fee. We found no exception that would require the Plan to pay for the telehealth facility fee. 
The records provided for review do not show that the telehealth facility fee was urgent or emergent. Therefore, 
we decided that the Plan does not have to pay for the telehealth facility fee provided on January 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan or derivative, Synvisc or Synvisc-One, for 
intra-articular injection (CPT code J7325). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says there is no documentation that it is medically necessary for the enrollee to be 
treated with this non-preferred agent. The Plan states there is no documentation that the enrollee has tried a 
preferred agent or why a preferred agent cannot be used. 
 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 medication. Our physician reviewer 
found the Plan requires a trial of drug Euflexxa, Durolane, Supartz-FX, Gelsyn-3 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection (CPT code 
J7325).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
April 2, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you should not be responsible for this 
copayment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for emergency care.  
 
You have been asked to pay a $110 copayment for an ER visit. An ER visit falls within the Emergency Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
provided on April 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
August 13, 2021 to August 18, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 pay for the 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found the review has determined that the records do not support that principal 
diagnosis code A41.9 - sepsis, unspecified organism or secondary diagnosis code R65.20 - severe sepsis 
without septic shock - were appropriate in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from August 13, 2021 to August 18, 2021.