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

 
We decided that the Plan does not have to waive the copayment for ambulance transportation on October 4, 
2021. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you have used this 
ambulance service previously and never received a bill. The Plan denied your request. The Plan says 
copayment 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 $225 
copayment for each Medicare-covered service or one-way trip by ground transportation.  
 
  You have been asked to pay $225 copayment for ambulance transportation. The ambulance transportation falls 
within the Ambulance 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 
ambulance transportation on October 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to approve non-emergent ambulance transportation. 
 
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 approve these services. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were 
contraindicated for this enrollee. He was being discharged in stable condition from acute care hospital to a 
subacute rehabilitation facility. The documentation does not support that the patient needed the expertise, 
services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe 
transport. The non-emergent transport is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to approve non-emergent ambulance transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) admission 
services. 
 
You asked the Plan to pre-approve the LTACH admission services. You say that the admission is medically 
necessary. The Plan denied your request. The Plan says the LTACH admission is not medically necessary. 
 
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 admission services. Our 
reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided documentation does not indicate there are 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 reviewer also found that 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 admission services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve long term acute care hospital (LTACH) admission services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical studies haven't proven that this service is helpful for treatment of the 
health problem. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the non-radiating midline back pain, the noted pain-aggravating and pain-relieving factors, 
along with the diminished and painful spinal motion (in all directions) and intact neurologic exam were/are all 
non-specific to any pathologic entities. In this case, there were/are multiple plausible pathologic sources of 
significant pain generation. Overall, documentation was/is lacking regarding reasonably detailed and/or 
evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of 
the enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested Intracept intraosseous nerve ablation at L4 and L5, in 
this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the upper spinal 
canal. 
 
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 notes do not show any physical therapy or activity modifications for at least six 
weeks. 
 
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 there are no red flags 
mandating immediate MRI of the cervical spine without a six week trial of physical therapy. There is no reflex 
abnormality or weakness documented. There is no plain x-ray report of the cervical spine or an 
electromyography in the records. Absent such data, the medical necessity of this MRI has not been 
demonstrated. 
 
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 upper spinal canal.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says a Medicare Advantage Plan can require a trial of a preferred drug to treat a medical 
condition before covering another non-preferred drug. 
 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 Plan requires a trial 
of Forteo before they will approve the requested drug. In this case, the patient has not tried and failed the 
required drug. There is no documentation provided indicating that the plans required drug would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Evenity for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive coinsurance for the cane provided on April 13, 2021. 
 
You asked the Plan to waive coinsurance for the cane. You say that you should not have to pay this bill because 
you never received a cane in the hospital. The Plan denied your request. The Plan says coinsurance 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 20% 
coinsurance for each Medicare-covered item.  
 
You have been asked to pay $4.74, which is 20% of the allowed amount for the cane. The allowed amount is 
$23.72 (20% x $23.72 = $4.74). The cane falls within the Durable medical equipment (DME) and related 
supplies benefit category. The medical records show the doctor requested a cane for you. 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 coinsurance for the cane provided on April 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Etoposide, Carboplatin, and Durvalumab. 
 
You asked the Plan to pre-approve the requested drugs. You say that this would be the best regimen to treat the 
enrollee. The Plan denied your request. The Plan says the mix of drugs is not supported for the enrollee's type 
of cancer. 
 
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 the requested drugs. Our physician 
reviewer found that the enrollee has a diagnosis of extrapulmonary small cell carcinoma of lymph nodes. The 
FDA has not stated that the requested drug regimen is indicated for the enrollee's condition. The Medicare 
approved cancer drug compendia do not contain a supportive citation for the use of the requested drugs in the 
enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. 
The documentation does not support that the requested drugs is safe and effective and otherwise reasonable and 
necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested drugs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Etoposide, Carboplatin, and Durvalumab.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient clinic visit and arthrocentesis 
provided on December 2, 2021. 
 
You asked the Plan to waive the copayment for the outpatient clinic visit and arthrocentesis.. You say that you 
received a cortisone shot in the doctors office. You say that it seems that the charge is exorbitant for a routine 
procedure. The Plan denied your request. The Plan says you have been charged the correct copayment 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 $450 
copayment for in-network outpatient hospital services.  
 
 
 You have been asked to pay a total of $308.67, which is less than the standard $450 copayment. The outpatient 
clinic visit and arthrocentesis fall 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 the outpatient clinic visit and arthrocentesis provided on December 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for mental health telehealth visits provided 
from October 11, 2021, to January 3, 2022. 
 
You asked the Plan to reduce the coinsurance for mental health telehealth visits. You say that the claims should 
all be processed with the same allowable amount because they are the same services by the same provider each 
week. You also say you request the claims be reprocessed as in-network due to a benefit misquote from an 
insurance representative.  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 30% 
coinsurance for each out-of-network outpatient mental health visit.  
 
You have been asked to pay 30% coinsurance for each mental health telehealth visit from October 11, 2021, to 
January 3, 2022.  
 
Date of Service Allowed Amount 30% Coinsurance 
October 11, 2021 $110.91 $33.27 
October 18, 2021 $110.91 $33.27 
November 8, 2021 $150.00 $45.00 
November 29, 2021 $110.91 $33.27 
December 6, 2021 $105.00 $31.50 
January 3, 2022 $150.00 $45.00 
Total  $234.81 
 
A mental health telehealth visit falls within the outpatient mental health visit 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 reduce the coinsurance for mental health telehealth visits provided from October 11, 2021, to 
January 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation is considered not medically 
reasonable and necessary and will not be covered when the diagnosis is anything other than osteoarthritis. 
 
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 Orthovisc. Our reviewer says that the 
requested drug, Orthovisc, does not meet the criteria for coverage. Our physician reviewer found the provided 
documentation does not indicate that the enrollee is on any medications/analgesics and the records do not 
document failed conservative treatment. The reviewer found that the enrollee has posterior horn meniscus 
derangement which is contributing to her symptoms of pain. Therefore, the reviewer found that the criteria for 
coverage have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Specifically, the file shows that the enrollee's 
posterior horn meniscus derangement is contributing to her symptoms of pain. Therefore, we decided that the 
Plan does not have to pre-approve Orthovisc (J7324).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to approve continued skilled nursing facility (SNF) services beyond 
May 17, 2022. 
 
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the admission is not medically necessary. 
 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you were admitted tot eh hospital to 
improve function due to weakness and deconditioning. You have no skilled nursing needs. You have no 
parental medications, complex wound care, or nutrition given via a feeding tube. You reached your maximum 
level of function as of May 17, 2022. You do not require any skilled nursing or rehabilitation services on a 
daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 
level of care. 
 
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 approve continued skilled nursing facility (SNF) services beyond May 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia. 
She has not tried and failed the Plan's required drugs, Infed and Venofer. The records do not support that the 
required drugs would be contraindicated or less effective; therefore, Feraheme is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. The Plan denied your request. The Plan says the enrollee has not 
tried Aranesp or Retacrit. 
 
 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 Procrit. Our physician reviewer found 
that the enrollee has metastatic small cell lung cancer and anemia due to antineoplastic chemotherapy. The Plan 
requires a trial of Aranesp or Retacrit before they will approve the requested drug. In this case, the enrollee has 
not tried and failed the required drugs. There is no documentation provided indicating that the Plans required 
drugs would likely be less effective or 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 Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH care and 
no skilled nursing facility will accept the enrollee for the near term and IRF care has been denied as well. The 
Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot be 
appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic 
advantage. 
 
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 all medically necessary care is being provided in the current acute care facility. 
 
 
 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.