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

We decided that the Plan does not have to pre-approve Revlimid for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. 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 Revlimid 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for chiropractic services provided from April 
30, 2021, to June 16, 2021. 
 
You asked the Plan to waive the copayments for chiropractic services. You say that you were told by the 
provider that you were fully covered. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 chiropractic services.  
 
You received chiropractic services from April 30, 2021, to June 16, 2021, for a total of 4 services. Therefore, 
you are responsible to pay a $20 copayment per each visit. The total amount you owe is: $80.  
You have been asked to pay the total copayment amount of $80 for chiropractic services. Chiropractic services 
fall within the chiropractic 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 copayments for 
chiropractic services provided from April 30, 2021, to June 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve left heart catheterization with ventriculography.
You asked the Plan to pre-approve left heart catheterization. You say that considering your condition and abnormal stress test, you need to proceed with this left heart catheterization. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because you do not meet the criteria for this procedure.
The Plan follows Medicare rules. Medicare rules state that left heart catheterization may be covered under certain conditions. 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 left heart catheterization. Our reviewer says that you meet the Medicare criteria for this procedure. Our physician reviewer found you have an intermediate pre-test probability of ischemic heart disease and symptoms of a possible anginal equivalent. Your nuclear stress test at a relatively low level of exercise was positive for apical ischemia. As noted in the rules, given these non-invasive test findings and your symptoms, you meet both the medical necessity and the applicable Medicare criteria for left heart catheterization, coronary angiography, and left ventriculography. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of left heart catheterization have been met. Therefore, we decided that the Plan has to pre-approve left heart catheterization with ventriculography.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 84550, 82306 and 83970) provided to the enrollee on April 26, 2021.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the referring claim was processed and paid on May 6, 2021. The Plan states the records reviewed do not include documentation for CPT codes 82306, 83970 and 84550 as performed by this billing provider on date of service April 26, 2021. The Plan states based on the missing documentation, the recommendation for CPT code(s): 82306, 83970 and 84550 is to uphold the original denial.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 82306, 83970 and 84550, billed by this provider was denied as a duplicate service to the same service billed on several claims for the same date of service. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 84550, 82306 and 83970) provided to the enrollee on April 26, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation provided does not indicate a failure, intolerance, or contraindication 
to Humira. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the case file does not 
contain any documentation of a trial of Humira. The documentation does not support that Humira would likely 
be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Stelara.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device (robotic arm) for the enrollee. 
 
You asked the Plan to pre-approve the arm. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental, investigational, and unproven. 
 
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 arm. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the 
enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and botox for spasticity if needed.  

The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or  to 
improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on 
scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. 
The MyoPro 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 enrollee, improve hemiparetic 
arm function, or be safe for long term use. There is 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 arm have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a powered upper extremity range of motion assist device (robotic arm) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee needs this for a diagnosis of Rheumatoid 
arthritis. 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 Humira 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits. 
 
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically 
necessary. The Plan denied your request. The Plan says additional PT is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 ten (10) additional PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally 
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health 
Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has 
been instructed in a home exercise program. The requested services are not part of a maintenance program, are 
the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or 
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical records do not show why this test is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that in this case, you are 
only stated to have a diagnosis of dizziness. There was no other mention of this condition in the records. In as 
much given the absence of pertinent and applicable clinical information, it cannot be independently determined 
that this MRI is otherwise 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the brain.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April 
26, 2021, to May 3, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that there should be no charges 
because the services were done incorrectly the first time. The Plan denied your request. The Plan says the 
copayment applied correctly based on the length of your stay. 

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 $275 
copayment per day for days 1 through 6 per benefit period for inpatient hospital care.  
 
You have been asked to pay a $275 copayment per day for 6 days of inpatient hospital care. ($275 x 6 = 
$1,650). 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 inpatient hospital care provided from April 26, 
2021, to May 3, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous spacer device 
(22869). 
 
You asked the Plan to pre-approve the insertion of a Superion interspinous spacer device. You say that the 
enrollee is not a candidate for other procedures. The Plan denied your request. The Plan says this 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 insertion of a Superion interspinous 
spacer device. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Superion device is experimental. More research is 
needed to show it is safe and effective. 
 
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 insertion of a Superion interspinous spacer device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous 
spacer device (22869).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 21, 2020.
You asked the Plan to pay for the lab services. You say that the specimens are from providers and must be processed without delay. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
We looked at the file and the rules. The claim lists the place of service as an independent laboratory. The records provided do not indicate the specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from August 5, 2020, 
to August 11, 2020, as billed with diagnosis related group (DRG) code 193. 
 
You asked the Plan to pay for inpatient services billed with DRG 193. You say that these services were billed 
correctly with the submitted DRG. The Plan denied your request. The Plan says DRG 193 is not supported in 
the record; DRG 194 is more appropriate as the medical record does not support a secondary diagnosis of 
Acute respiratory failure with hypoxia (J96.01). 
 
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. DRG 193 requires a secondary diagnosis of Acute 
respiratory failure with hypoxia (J96.01). 
 
In this case, inpatient services were billed with DRG 193. 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 inpatient services billed with DRG 193. Our reviewer says that the submitted DRG is not supported. 
Our physician reviewer found that based on the records provided, there was no clear documentation of 
respiratory rate of 30 or above, accessory muscle use, hypoxia beyond baseline, or use of bilevel positive 
airway pressure (BiPAP) or mechanical ventilation to help support the diagnosis of acute respiratory 
failure. Acute respiratory failure with hypoxia is not supported as a secondary diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the medical records do no substantiate the DRG as billed. Therefore, we decided that the Plan does not have to 
pay for the inpatient hospital services provided from August 5, 2020, to August 11, 2020, as billed with 
diagnosis related group (DRG) code 193.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits. 
 
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically 
necessary. The Plan denied your request. The Plan says additional PT is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 ten (10) additional PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally 
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health 
Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist, or by or under the supervision of a therapist. He is at a 
supervision level for bed mobility, transfers, and ambulation. He does not require ongoing skilled professional 
therapy. The requested services are not part of a maintenance program, are the specialized skill, knowledge and 
judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the 
enrollee's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4291 x 2) and localized delivery of 
antimicrobial agents (D4381) provided on July 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that your gums were infected. You say that if you 
did not have the procedure done, your teeth would have to be extracted. You also say that The Plan denied your 
request. The Plan says there is an $1,000 allowance for all covered dental services. The Plan also says that the 
allowance has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental services have not been met. Specifically, the allowance has been exhausted. The record 
shows that the Plan paid $334 for dental services that you received on July 21, 2021. The record shows that the 
Plan reprocessed the claim in this case and paid the full amount for the gingival irrigation and localized 
delivery of microbial agents. The total amount the plan paid for this claim was $666 with a member liability of 
$12. $334 + $666 = $1,000. The Evidence of Coverage clearly states that you pay 100% of charges beyond the  
$1,000 allowance or if you exceed a service limit. Therefore, we decided that the Plan does not have to pay an 
additional amount for the dental services provided on July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery has 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspirate remains experimental. More research is needed to show safety and efficacy. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate for the enrollee.