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

 
We decided that the Plan does not have to waive the copayment for a denosumab injection provided on January 
20, 2022. 
 
You asked the Plan to waive the copayment for a denosumab injection. You say that you were not made aware 
of this copayment and feel you should not have to pay it. The Plan denied your request. The Plan says the 
copayment applied was 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 a 20% 
coinsurance for Medicare Part B drugs. The allowed amount of this item is $1272.60, resulting in a coinsurance 
amount of $254.52 ($1272.60 x 20% = $254.52). 
 
You have been asked to pay a $254.52 coinsurance for a denosumab injection. A denosumab injection falls 
within the Medicare Part B drugs 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 
denosumab injection provided on January 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided the Plan does not have to pre-approve a pharmacy retrieved injection of Synvisc for the enrollee. 
 
You asked the Plan to pre-approve injections not taken from physician or facility stock. You say that this 
injection is medically necessary. The Plan denied your request. The Plan says this injection cannot be covered 
by Medicare unless taken from physician stock. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve a pharmacy retrieved injection of Synvisc for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from March 3, 
2022, to March 5, 2022 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you were unaware of your 
copayment, and you are on a fixed income and cannot afford this. The Plan denied your request. The Plan says 
the copayment applied was 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 a $245 
copayment for days 1 to 5 for inpatient hospital care ($245 x 2 days = $490). 
 
You have been asked to pay a $490 copayment for 2 days of an inpatient stay. An inpatient stay falls within the 
Inpatient Hospital Care 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 an inpatient 
stay provided from March 3, 2022, to March 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gastric peroral endoscopic myotomy (G-POEM). 
 
You asked the Plan to pre-approve Gastric peroral endoscopic myotomy (G-POEM). You say that the 
requested Gastric peroral endoscopic myotomy (G-POEM) is medically necessary. The Plan denied your 
request. The Plan says the requested Gastric peroral endoscopic myotomy (G-POEM) is not medically 
necessary. 
 
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 Gastric peroral endoscopic myotomy 
(G-POEM). Our reviewer says that the requested Gastric peroral endoscopic myotomy (G-POEM) is not 
medically necessary. Our physician reviewer found peroral endoscopic myotomy (POEM) has been adapted to 
performance in the stomach (termed gastric or G-POEM) for the treatment of severe medically refractory 
gastroparesis, such that endoscopic pyloromyotomy (G-POEM) procedure myotomizes the pylorus. For G-
POEM, a submucosal tunnel is typically created 5 cm proximal to the pylorus along the greater curvature or 
anterior gastric wall. A 2 cm antral myotomy is then performed in addition to pyloromyotomy via the 
submucosal tunnel.  
Several case reports show that G-POEM in some cases offers benefit in management of severe refractory 
gastroparesis. Limited data has demonstrated normalization in 47-70% of gastric emptying rates, and reduction 
in nausea and vomiting (but not bloating) in up to 86% of patients. In Malik's recent series, 33% of patients 
experienced no benefit or worsening of gastric emptying. Durability of response is uncertain, and longer 
duration of disease has been associated with lower 1-year outcomes. Recorded complications, from 6.7-14.3%, 
include: pyloric channel and prepyloric ulceration, pneumoperitoneum. 
 
However, all cited authors agree that G-POEM is still a novel technique that while promising is not standard-
of-care. Further, no objective recent data was presented with Appellant's records that demonstrate significant 
gastroparesis beyond early phase of gastric emptying. Available record in fact documents a morbidly obese 
body mass index of 36.73 in this enrollee who her provider characterizes as "in no apparent distress." The 
argument for medical necessity of G-POEM in Appellant's case is not supported by available records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gastric peroral endoscopic myotomy (G-POEM) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Gastric peroral endoscopic myotomy (G-POEM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and do not 
require transfer to an LTACH. 
 
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. You are 
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. Our physician reviewer found 
that your condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 30, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. 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 $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 30, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided March 3, 2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. Since this panel includes the 
FANCC gene, the denial is correct. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to an enrollee with non-small cell lung 
cancer. The FDA approval notice indicates that this panel is approved for non-small cell lung cancer. No other 
valid denial rationale was presented by the Plan. Based on this information, we decided that Medicare rules for 
coverage of the F1CDx testing have been met. Therefore, we decided that the Plan has to pay for the 
FoundationOne CDx (F1CDx) testing provided March 3, 2022.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on May 
4, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you should not have to pay this 
copayment as you were dissatisfied with the received care. The Plan denied your request. The Plan says the 
copayment applied was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $120 copayment for emergency care.  
 
The enrollee been asked to pay the allowed amount of $86.02, which is less than the $120 copayment for an ER 
visit. An ER visit falls within the Emergency Care benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for an emergency room visit provided on May 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
February 23, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. 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 $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient clinic visit provided on  
April 5, 2022. 
 
You asked the Plan to waive the copayment for an outpatient clinic visit. You say that you were not told by the 
provider a copayment was due at time of visit. You say that you disagree with the way the visit is being billed 
as an "outpatient hospital stay" and you were unaware of how expensive the visits were. 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 a $125 
copayment for all other outpatient services not provided in an ambulatory surgical center.  
 You have been asked to pay a $125 copayment for an outpatient clinic visit. An outpatient clinic visit 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 an outpatient clinic 
visit provided on April 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ongentys capsules, 50mg 
 
You asked the Plan to pre-approve Ongentys capsules. You say that the enrollee has tried and failed many other 
medications. The Plan denied your request. The Plan says Ongentys capsule is considered a prescription drug 
only covered under Medicare Part D. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Ongentys capsules, 50mg  
 
Benefits for Ongentys capsules 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: 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 Intracept procedure. You say that the requested Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is not 
medically necessary. 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the 
Intracept procedure is experimental. More research is needed. The procedure is not considered medically 
reasonable 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient clinic visit provided on  
March 1, 2022. 
 
You asked the Plan to waive the copayment for an outpatient clinic visit. You say that you were not told by the 
provider a copayment was due at time of visit. You say that you disagree with the way the visit is being billed 
as an "outpatient hospital stay" and you were unaware of how expensive the visits were. 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 $125 
copayment for all other outpatient services not provided in an ambulatory surgical center.  
 You have been asked to pay $125 copayment for an outpatient clinic visit. An outpatient clinic visit 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 an outpatient clinic visit 
provided on March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee walker (E0118) for the enrollee. 
 
You asked the Plan to pre-approve a knee walker. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch 
substitutes (E0118). 
 
We looked at the file and Medicare rules. The DME MAC, the contractor responsible for coverage of medical 
equipment in the State of Virginia has decided that the knee walker coded as E0118 is not medically reasonable 
and necessary. Therefore, we decided that the Plan does not have to pre-approve a knee walker (E0118) for the 
enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 19, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were informed there would 
be no charge for the services. 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 $20 
copayment for physical therapy visits.  
 You have been asked to pay a $20 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that this is medically necessary. The Plan denied your 
request. The Plan says viscosupplementation was previously ineffective. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Gel-One. Our reviewer says that the 
requested use of Gel-One is not supported. Our physician reviewer found the records clearly document that the 
enrollee received no benefit from the Orthovisc injections. Given the enrollee's failure of prior 
viscosupplementation therapy, the Gel-One does not  meet Medicare criteria for medically 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) 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 records do not show that the enrollee has an indication for 
continued monitoring. 
 
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. The patient has a 
history of syncope in 2019 without evidence for an arrhythmic etiology. As such, based on current guidelines 
and the documentation provided, there is insufficient clinical evidence to support the medical appropriateness 
and necessity of replacing the patients old ILR with a new ILR. 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 an implantable loop recorder (ILR) for the enrollee.