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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's current functional and medical condition does not support 
the SNF request. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
SNF services are not medically reasonable and necessary. There are no identifiable skilled nursing or therapy 
service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This 
beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power standing system (CPT code E2301). 
 
You asked the Plan to pre-approve a power standing system. You say that the item is necessary. The Plan 
denied your request. The Plan says this is not covered because they are not primarily medical in nature and 
there was no documentation of need for a power standing system from your physiatry evaluation. 
 
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 a power standing system have not been met. The rules say that a 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. Therefore, 
we decided that the Plan does not have to pre-approve a power standing system (CPT code E2301).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on October 2, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you fell and twisted your foot. You say that 
the ambulance was called. You say that they checked to make sure your foot was not broken. You also say that 
you did not go to the emergency room as you were advised it was not broken and were able to move it. The 
Plan denied your request. The Plan says since there was not transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 2, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on October 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM (CPT code(s): K0554 and K0553). 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee is having difficulty checking their blood 
sugar with a standard meter due to their tremors. The Plan denied your request. The Plan says the Medicare 
rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The enrollee is not on insulin three or more times a day with frequent 
adjustments or on a continuous insulin pump.  Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
CGM (CPT code(s): K0554 and K0553).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of 
the brain (including brain stem); without contrast material, followed by contrast material(s) and further 
sequences (70553) provided on March 4, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 
copayment for Medicare-covered magnetic resonance angiography (MRA), magnetic resonance imaging 
(MRI), and angiogram at a freestanding provider or an outpatient hospital setting.   
You have been asked to pay a $95 copayment for the Medicare-covered MRI provided. 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 magnetic resonance imaging (MRI) of the brain (including brain 
stem); without contrast material, followed by contrast material(s) and further sequences (70553) provided on 
March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the right arm MyoPro Motion G Orthotic device (CPT 
code L8702). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says a review of current medical literature shows that these service(s) do not have proven 
benefit and are considered experimental/investigational. The Plan states they are not identified as widely used 
and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical 
literature published in the English language. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that the MyoPro Motion G Orthotic device at issue in this case meets 
Medicare criteria for medically reasonable and necessary. Current clinical guidelines designate robotic therapy 
to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with 
unproven benefit in the home environment.  
 
 Although records from the device manufacturer/vendor argue medical necessity of the requested device, no 
records from the enrollees actual treating provider clarify why the requested device is the most appropriate 
treatment for the enrollees condition and that the enrollee has been able to successfully use the device. No 
physical therapy or occupational therapy records are provided showing failure of conventional treatment and 
successful use of the MyoPro Motion G Orthotic device. 
 
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 right arm MyoPro Motion G Orthotic device (CPT code L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Synvisc-One knee injection (J7325) 
administered by an in-network provider on February 14, 2022. 
 
You asked the Plan to waive the coinsurance for a knee injection. You say that you believe you are being 
overcharged after reviewing your benefits online. You believe the provider should fully cover the service. The 
Plan denied your request. The Plan says the cost-share was applied correctly, according to your contract. 
 
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% 
coinsurance for Medicare Part B Prescription Drugs when provided in-network.  
 
 
 
 You have been asked to pay a 20% coinsurance for a knee injection. Knee injections fall within the Medicare 
Part B Prescription Drugs benefit category. You received this service from an in-network provider. Medicare-
covered Part B allergy antigens are fully covered; however, all other Medicare-covered Part B drugs require a 
20% coinsurance when provided in-network. Please see below for a breakdown of your cost-share. 
 
Plan Allowed Amount: $1,079.04  20% coinsurance = $215.81 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for a Synvisc-One knee injection (J7325) administered by an 
in-network provider on February 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, abdomen (74018) provided on 
November 19, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that the enrollee is in a nursing home for which 
you have an exclusive contract with, which means only you can come into the facility to perform services for 
patients in need. The Plan denied your request. The Plan says enrollees must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 
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 the radiologic examination, abdomen (74018) 
provided on November 19, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on March 2, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that the referring provider sent the enrollee to 
your facility for services. The Plan denied your request. The Plan says the rendering or referring providers are 
both OON providers and there was no approved authorization. Also, the service rendered was not urgent or 
emergent. 
 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 the radiology services provided on March 2, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visit (99337) provided on October 29, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the service was provided out-of-network and was not approved in 
advance. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home health visit (99337) provided on October 
29, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nebulizer, with compressor (E0570) 
provided on October 20, 2020. 
 
You asked the Plan to waive the copayment for the nebulizer. You say that the services should be covered as 
you disagree with the charges, were not made aware of them, and they accumulated over time. The Plan denied 
your request. The Plan says the coinsurance applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Durable Medical Equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the nebulizer (allowed is $12.17 x 20% = $2.43). 
Nebulizers fall within the Durable Medical Equipment (DME) and related 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 nebulizer, with compressor (E0570) provided on October 
20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan. 
 
You asked the Plan to pre-approve Xifaxan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Xifaxan.  
 
 
 Benefits for Xifaxan 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: 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 the enrollee will clearly benefit from IRF care to 
optimize his level of functioning prior to returning home. The Plan denied your request. The Plan says an 
intensive rehabilitation program is not medically necessary. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nebulizer, with compressor (E0570) 
provided on May 20, 2020. 
 
You asked the Plan to waive the copayment for the nebulizer, with compressor. You say that the services 
should be covered as you disagree with the charges, were not made aware of them, and they accumulated over 
time. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services 
provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Durable Medical Equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the nebulizer, with compressor (allowed is $7.50 x 20% = 
$1.50). Nebulizers, with compressors fall within the Durable Medical Equipment (DME) and related 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 nebulizer, with compressor 
(E0570) provided on May 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nebulizer, with compressor (E0570) 
provided on June 20, 2020. 
 
You asked the Plan to waive the copayment for the nebulizer, with compressor. You say that the services 
should be covered as you disagree with the charges, were not made aware of them, and they accumulated over 
time. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services 
provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Durable Medical Equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the nebulizer, with compressor (allowed is $12.17 x 20% = 
$2.43). Nebulizers, with compressors fall within the Durable Medical Equipment (DME) and related 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 nebulizer, with compressor 
(E0570) provided on June 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that you would like the plan to reconsider their 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 Evenity. 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 age-related osteoporosis who has failed treatment with Fosamax. The 
documentation does not support that the enrollee has tried and failed Forteo. The documentation does not 
support that Forteo 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.