Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a sacroiliac joint injection performed on 
April 12, 2022. 
 
You asked the Plan to waive the copayment for the injection. You say that the injection did not work. 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 $200 
copayment per visit for surgery or other services at an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay a $200 copayment for the injection. The injection falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 sacroiliac joint injection performed on April 
12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removable foot inserts (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve removable foot inserts (L3000).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
breast provided on April 25, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you are on a fixed income and were not 
aware of the copayment. 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 $275 
copayment for each diagnostic imaging service, including MRI's.  
 
You have been asked to pay a $275 copayment for the MRI. The MRI falls 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 a magnetic resonance imaging (MRI) of the breast provided on April 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat Supartz injections. 
 
You asked the Plan to pre-approve repeat Supartz injections. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat series of hyaluronan knee injection(s) is 
covered when at least six months have elapsed since the prior series of injections. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee received Supartz injections 
to the right knee on May 10, 2022, May 17, 2022, and May 24, 2022. Six months have not passed since the 
enrollee's prior series of injections. Based on this information, we decided that Medicare rules for coverage of 
repeat Supartz injections have not been met. Therefore, we decided that the Plan does not have to pre-approve 
repeat Supartz injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this care is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is a 66-year-old male with a history of hypertension and Hepatitis C. Based on the documentation provided, the enrollee does not require the intensity of services provided at an 
IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation. The enrollees care needs can be met at a lower level of care at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive the copayment for an electrocardiogram (ECG) performed on 
February 25, 2022. 
 
You asked the Plan waive the copayment for an ECG performed on February 25, 2022. You say that the plan 
should pay for test as it is routine and necessary. The Plan denied your request. The Plan says you are 
responsible for to pay a $14.10 copayment for an ECG. 
 
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 Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $14.10 copayment for an ECG. An ECG falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. Since the Plans allowance is less than your 
contracted copayment, you are only being held responsible for the lesser amount. 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 
waive the copayment for an electrocardiogram (ECG) performed on February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetics (L5301, L5620, L5940, L5910, L5629, 
L5645) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the prosthetics. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not 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 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 
prosthetics (L5301, L5620, L5940, L5910, L5629, L5645) to be provided by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab (J9271) and Carboplatin (J9045). 
 
You asked the Plan to pre-approve Pembrolizumab and Carboplatin. You say that you feel the regimen 
requested makes a great deal of sense for this patient. The Plan denied your request. The Plan says there was 
insufficient diagnostic workup done, and the regimen is not appropriate based on the information the provider 
submitted. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Pembrolizumab and Carboplatin. Our 
reviewer says that Pembrolizumab and Carboplatin are not reasonable and necessary. Our physician reviewer 
found that the full information on the Estimated Glomerular Filtration Rate (eGFR) mutation is not available in 
the records. Without this information, this requested drug regimen without Alimta is not approvable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pembrolizumab and Carboplatin have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Pembrolizumab (J9271) and Carboplatin (J9045).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sensor; invasive, disposable, for use with interstitial 
continuous glucose monitoring (CGM) system (A9276) and a transmitter; external, for use with interstitial 
CGM system (A9277). 
 
You asked the Plan to pre-approve a CGM sensor and transmitter. You say that you need your supplies, and 
your current pump is working. The Plan denied your request. The Plan says your glycemic control is great, and 
you change monitors for convenience. The plan provided a CGM in August 2018. Per CMS guidelines, criteria 
have not been met for replacement of your CGM as it has not exceeded its reasonable useful lifetime, is not 
irreparably damaged or worn, and is not malfunctioning. 
 
The Plan must follow Medicare rules. Medicare rules say that there are guidelines that state when equipment 
replacement is medically needed. 
 We looked at the file and Medicare rules. The guidelines state that equipment can be replaced if your current 
equipment is damaged, your medical condition has changed or if the warranty of your equipment has expired. 
The documentation indicates that your current equipment is under warranty until 2026, therefore, the 
replacement CGM and supplies are not covered. Based on this information, we decided that Medicare rules for 
coverage of a CGM sensor and transmitter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sensor; invasive, disposable, for use with interstitial continuous glucose monitoring 
(CGM) system (A9276) and a transmitter; external, for use with interstitial CGM system (A9277).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiovascular monitoring services 
provided on January 18, 2022. 
 
You asked the Plan to waive the copayment for cardiovascular monitoring services. You say that since there 
was not an actual visit it should be covered. The Plan denied your request. The Plan says the copayment 
applied 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). Your contract with the Plan clearly says that you must pay $15 
copayment for each Medicare-covered non-radiological diagnostic service at a specialist office.  
 
 
 
 You have been asked to pay $15 copayment for cardiovascular monitoring services. Cardiovascular monitoring 
services falls 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 cardiovascular monitoring services provided on January 18, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic DME (E0667, E0651) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic DME. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 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 
pneumatic DME (E0667, E0651) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. A request for information was faxed to the Plan on July 11, 2022, requesting 
medical records and we did not receive a response. Therefore, we decided that the Plan has to pre-approve 
skilled nursing facility (SNF) care.  
 
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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be rendered by the out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that you must use in-network providers for all  
non-urgent care. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy services to be rendered by the out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided no January 31, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says these services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that a professional component 
(PC)/technical component (TC) indicator of 8 identifies professional component of clinical laboratory codes for 
which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8. The records show that the services were not performed in the inpatient setting. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services provided no January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve a power operated vehicle. 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 follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power operated vehicle. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the documentation notes the 
enrollee has a mobility deficit, but the documentation does not support that the mobility limitation significantly 
impairs her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as 
toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The documentation 
does not support that the enrollee's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted walker. She is able to walk 30 feet at a time with breaks. The documentation does not 
support that the use of a requested wheelchair will significantly improve the enrollee's ability to participate in 
MRADLs. The power operated vehicle is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated vehicle.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for wound care services provided on January 7, 
2022. 
 
You asked the Plan to waive the deductible for the wound care. You say that the enrollee should not have been 
responsible since the wounds were a result of improper care. The Plan denied your request. The Plan says the 
correct amount was applied to the enrollee's 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 $500 deductible which applies to certain items and services.  
 
The wound care you asked the Plan to waive the deductible for falls within the Outpatient Surgery and Other 
Medical 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 $500 deductible which 
applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the 
time the wound care was received on January 7, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for wound care services provided on January 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prolotherapy. 
 
You asked the Plan to pre-approve prolotherapy. You say that the requested Prolotherapy is medically 
necessary. The Plan denied your request. The Plan says the requested Prolotherapy is not covered by Medicare 
or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that prolotherapy is not covered by Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of prolotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 
prolotherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable neurostimulator. 
 
You asked the Plan to pre-approve an implantable neurostimulator. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that PENS is only covered when performed in a 
physician's office, clinic, or hospital outpatient department. 
 
We looked at the file and Medicare rules. Review of the file shows that the requested device is not being used 
in a physician's office, clinic, or hospital outpatient department. Based on this information, we decided that 
Medicare rules for coverage of an implantable neurostimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an implantable neurostimulator.