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

 
We decided that the Plan does not have to waive the copayment for a comprehensive hearing test provided on 
December 23, 2021. 
 
You asked the Plan to waive the copayment for the comprehensive hearing test. You say that you thought the 
test was free. 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 $25 
copayment for each diagnostic hearing exam.  
 
You have been asked to pay a $25 copayment for the comprehensive hearing test. The comprehensive hearing 
test falls within the Hearing 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 waive the copayment for a 
comprehensive hearing test provided on December 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar laminectomy and inpatient hospital stay. 
 
You asked the Plan to pre-approve a lumbar laminectomy and inpatient hospital stay. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 lumbar laminectomy and inpatient 
hospital stay. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the records do not document a 6-week trial of physical 
therapy for back pain. There is no discharge note from a physical therapist or documentation of recent and 
adequate physical therapy. More conservative measures are needed. 
 
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 lumbar laminectomy and inpatient hospital stay have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a lumbar laminectomy and inpatient hospital stay.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for privigen infusion services 
performed on November 30, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the infusion services. You say that you would 
like a fair copayment for the services. You say that insurance always paid more for previous procedures. The 
Plan denied your request. The Plan says the correct copayment and coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for surgery or other services provided at an outpatient hospital. Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each Part B drug. 
 
You have been asked to pay $282.09 for the infusion services, which is less than the $350 copayment. The 
infusion services fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. You have also been asked to pay $533.76 for the 
drug privigen, which is 20% of the allowed amount ($2,668.80 allowed amount x 20% coinsurance = $533.76). 
The drug privigen falls within the Medicare Part B Prescription Drugs benefit category. The total for the visit is 
$815.85. 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 and coinsurance for privigen infusion services 
performed on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network 
(OON) provider on December 20, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on  
December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation (unattended) other than wound care, a 
therapeutic, prophylactic, or diagnostic injection, a therapeutic procedure on 1 or more areas, a vasopneumatic 
device therapy, an unknown drug injection, a thiamine hcl 100 mg injection, a pyridoxine hcl 100 mg injection, 
and a levocarnitine injection provided on July 19, 2021, by an out-of-network (OON) provider.  
You asked the Plan to pay for electrical stimulation (unattended) other than wound care, a therapeutic, 
prophylactic, or diagnostic injection, a therapeutic procedure on 1 or more areas, a vasopneumatic device 
therapy, unknown drug injections, a thiamine hcl 100 mg injection, a pyridoxine hcl 100 mg injection, and a 
levocarnitine injection. You say that you are appealing with supporting records. The Plan denied your request. 
The Plan says the member's primary care provider did not refer for services, and no medical necessity for an 
out-of-network provider, such as an urgent or emergency situation, has been documented. The Plan also says 
there is no network deficiency for these services and alternate network providers were found. 
 
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 electrical stimulation (unattended) other than 
wound care, a therapeutic, prophylactic, or diagnostic injection, a therapeutic procedure on 1 or more areas, a 
vasopneumatic device therapy, an unknown drug injection, a thiamine hcl 100 mg injection, a pyridoxine hcl 
100 mg injection, and a levocarnitine injection provided on July 19, 2021, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on January 3, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you do not agree with the 
copayment applied. The Plan denied your request. The Plan says the copayment applied correctly. 
 
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 per visit for urgent care visits. 
 
You have been asked to pay $45 for the urgent care visit. An 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 waive the copayment for the urgent care visit 
provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Office visit and percutaneous tests to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve Office visit and percutaneous tests. You say that you are requesting to see 
this provider for continuity of care. The Plan denied your request. The Plan says the provider is out-of-network 
and it was determined these services can be received in-network. 
 
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 
Office visit and percutaneous tests to be provided 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 hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient hospital care is 
medically reasonable and necessary following surgery. The Plan denied your request. The Plan says the 
inpatient care following surgery is not necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the patient is a 60-year-old female who has unilateral primary osteoarthritis if the left hip and was approved for an elective hip replacement surgery. This is a request for inpatient services 
related to this procedure. However, the provided documentation revealed the patient as stable and without high-
risk conditions that would expect them to require hospital care that would likely cross two midnights for this 
typically ambulatory procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the enrollee will need repeat iron infusions because 
of such low iron levels. The Plan denied your request. The Plan says the denial of authorization for these drugs 
is correct, because the Plan requires a trial of Infed and Venofer before it will approve Injectafer. 
 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 Injectafer. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Injectafer. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of Infed and Venofer. The record does not 
show that these drugs would likely be less effective and/or 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Injectafer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for subsequent hospital care provided on 
December 3, 2021. 
 
You asked the Plan to waive the deductible for the subsequent hospital care. You say that you had already met 
your deductible. The Plan denied your request. The Plan says the correct amount was applied to your 
deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,484 deductible for Part A, and a $203 deductible for Part B which 
applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,484 
deductible for Part A, $203 deductible for Part B which applies to certain items and services. This cost sharing 
is a contractual obligation that had not been met at the time the subsequent hospital care was received on December 3, 2021. Therefore, we decided that the Plan does not have to waive the deductible for subsequent 
hospital care provided on December 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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. Our 
physician reviewer found that the patient is a 73-year-old female who was admitted to the acute care hospital 
with chronic obstructive pulmonary disease exacerbation and acute respiratory failure, atrial flutter, and acute 
renal failure. They were treated with mechanical ventilation support. Recent notes describe the patient as 
improving with treatment, with resolved renal failure and now tolerating high flow oxygen, but with persistent 
leukocytosis. The patient appears to be more stable and improving and should only require short-term 
additional acute care hospital services that can safely be administered at the current facility. The patient does 
not require services at the LTACH that are not already available at the current facility. There are no services at 
the LTACH that the patient requires that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of 
care may be considered when treatment has completed. 
 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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. Our 
physician reviewer found 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. The health plan has approved ongoing care 
in the current acute care facility. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Elbow orthosis (L8702). 
 
You asked the Plan to pre-approve the MyoPro Elbow orthosis. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this item is experimental. 
 
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 MyoPro Elbow orthosis. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients and is not in widespread use 
based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for long term 
use. There is also insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 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 MyoPro Elbow orthosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the MyoPro Elbow orthosis (L8702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer Nasal Airway Remodeling procedure. 
 
You asked the Plan to pre-approve the VivAer Nasal Airway Remodeling procedure. You say that the service 
is medically necessary. The Plan denied your request. The Plan says this service is experimental. 
 
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 VivAer Nasal Airway Remodeling 
procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found there is no substantive evidence that immediate RFA-assisted 
reduction of intranasal soft tissue to enlarge the INV is superior to the various other procedural techniques 
currently available. A systematic review of randomized trials by Mirza et al. (Rhinology, 2020) concluded that 
microdebrider-assisted inferior turbinate reduction was superior to RFA in terms of clinical short- and long-
term outcomes, notably anterior active rhinomanometry at 2-year follow-up and Visual Analogue Scale at 3-6 
months, 1 year, and 2 years. In summary, the requested VivAer device does not meet criteria for being 
medically reasonable and necessary to manage the patients nasal airway obstruction. 
 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 VivAer Nasal Airway Remodeling procedure have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the VivAer Nasal Airway Remodeling procedure.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode array (63650) and implantable neurostimulator electrode (L8680). 
 
You asked the Plan to pre-approve the percutaneous implantation of neurostimulator electrode array and 
implantable neurostimulator electrode. You say that the service is medically necessary. The Plan denied your 
request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Dorsal column stimulators may be covered as 
therapies for the relief of chronic intractable pain under the circumstances 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 the percutaneous implantation of 
neurostimulator electrode array and implantable neurostimulator electrode. Our reviewer says that the service is 
not medically necessary. Our physician reviewer found you do not have any evidence based indication for a 
SCS trial. 
 
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 percutaneous implantation of neurostimulator electrode array and 
implantable neurostimulator electrode have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the percutaneous implantation of neurostimulator electrode array (63650) and implantable 
neurostimulator electrode (L8680).