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

 
We decided that the Plan does not have to pay for acupuncture treatment provided on April 4, 2022. 
 
You asked the Plan to pay for acupuncture treatment. You say that should be able to receive up to 20 
acupuncture treatments per year from an in-network provider at the $35 specialist visit rate. The Plan denied your request. The Plan says unilateral primary osteoarthritis, left knee is not a diagnosis that supports an 
acupuncture service for lower back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the file shows that the acupuncture treatment is not 
for the diagnosis of chronic low back pain (CLBP). Therefore, we decided that the Plan does not have to pay 
for acupuncture treatment provided on April 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home COVID-19 self-tests purchased on January 20, 
2022, and January 21, 2022. 
 
You asked the Plan to pay for COVID-19 self-tests. You say that these services should be covered under the 
public health emergency executive order. The Plan denied your request. The Plan says these services were not 
covered by Medicare on the date they were purchased. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and COVID-19 
self-tests is an OTC item. The rules say that Medicare coverage of COVID-19 self-tests began on April 4, 
2022. Tests obtained prior to this date are not eligible for Medicare payment. Please also note that the order 
cited in your appeal applies to private and group health insurance rather than Medicare. Therefore, we decided 
that the Plan does not have to pay for at-home COVID-19 self-tests purchased on January 20, 2022, and 
January 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-sterile gloves. 
 
You asked the Plan to pre-approve these services. You say that the gloves are needed to manage your home 
health care. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that non-sterile gloves are not covered because they are 
hygienic items that are non-reusable. 
 
We looked at the file and Medicare rules. The requested non-sterile gloves are not covered by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve non-sterile gloves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you believe if 
the treatment records were reviewed, it would become abundantly and clinically clear that a simple leg pump is 
not appropriate for this unfortunate enrollee. The Plan denied your request. The Plan says the enrollee does not 
meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic 
pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0656, E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc (J7327). 
 
You asked the Plan to pre-approve Monovisc. The Plan denied your request. The Plan says this appeal request 
is for Monovisc which does not meet requirements for coverage. 
 
  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 Monovisc. Our reviewer says that 
Monovisc is not reasonable and necessary. Our physician reviewer found the provided records do not indicate 
that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that 
the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred step one 
alternative. Our reviewer also found that the elements of the coverage criteria are not satisfied. The requested 
service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc (J7327).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on March 13, 2020. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance needed to come but it did not transport you because the family took you. The Plan denied your 
request. The Plan says this service is not a covered benefit. The Plan also says that you did not wish to be taken 
to the hospital, but only wanted to have your vitals taken. 
 
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 March 13, 2020. 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 with no 
transport (A0998) provided on March 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that an 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. The 
enrollee was admitted for peripheral vascular disease and had a below the knee amputation. His medical 
problems are stable. He does not have complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
Additionally, there is not a reasonable expectation that this 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transcatheter placement procedure 
performed on December 17, 2021. 
 
You asked the Plan to waive the copayment for the transcatheter placement. You say that you feel this is a 
basic procedure that should be fully covered. 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 $350 
copayment per day for surgery or services provided at an outpatient hospital facility.  
 
You have been asked to pay a $350 copayment for the transcatheter placement. The transcatheter placement 
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 
transcatheter placement procedure performed on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care services performed on 
September 7, 2021. 
 
You asked the Plan to waive the copayment for the wound care. You say that you did not have surgery. 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 $320 
copayment for surgery or services in an outpatient hospital.  
 
The record shows that wound care services were performed for a foot ulcer. Therefore, you have been asked to 
pay $182.63, which is less than the $320 copayment for the wound care. The wound care 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 wound care services 
performed on September 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional skilled nursing visits (G0299). 
 
You asked the Plan to pre-approve additional skilled nursing visits. The Plan denied your request. The Plan 
says the requested visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 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 additional skilled nursing visits. Our 
reviewer says that the requested home health services are not medically necessary. Our physician reviewer 
found the documentation does not support that you require additional skilled nursing services to provide 
treatment that is medically necessary. You do not require additional skilled nursing services to effectively 
provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to 
maintain your condition and/or prevent deterioration. Our reviewer also found that you have been medically 
stable without any recent exacerbations of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional skilled nursing visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional skilled nursing visits (G0299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and 
services provided from January 17, 2022, to January 22, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were told you would 
have a $50 copayment for the surgery. The Plan denied your request. The Plan says this claim was processed 
correctly, and your copayment was assessed in accordance with your contract. There is no record of a call 
placed to the health plan regarding your benefits prior to this admission. 
 
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 $250 
copayment for each inpatient hospital admission.  
 
You have been asked to pay a $250 copayment for inpatient hospital care. While the Plan contract does state 
that there is a $50 copayment for outpatient surgery, the record shows that this service was performed in an 
inpatient setting, not outpatient, and you were admitted as inpatient status for six days. Therefore, the inpatient 
hospital admission copayment applies in this case. 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 inpatient hospital admission and services provided from January 17, 2022, to January 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation (D9222, D9223). 
 
You asked the Plan to pre-approve sedation. You say that you need to have a tooth removed and have a crown 
replaced. The Plan denied your request. The Plan says deep sedation (D9222, D9223) is not covered by your 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep 
sedation (D9222, D9223).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on March 14, 2022. 
 
You asked the Plan to reduce the copayment for the CT scan. You say that you were informed that your 
copayment would only be $10. 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 $325 
copayment per day for diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $325 copayment for the CT scan. Please note that the $10 copayment is only for 
non-radiological tests. The CT scan 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 reduce the copayment for a computed tomography 
(CT) scan of the abdomen and pelvis provided on March 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that this is medically necessary. The Plan denied your 
request. The Plan says that your provider does not provide a rationale for use of the non-preferred product for 
safety or efficacy. 
 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 Durolane. Our reviewer says that 
Durolane is not medically reasonable and necessary. There is no indication that you have tried and failed 
Orthovisc, Synvisc or Synvics One. There is no indication that the Plan's required drugs would likely be less 
effective and/or likely have adverse effects for you. Our physician reviewer found that your condition does not 
meet step therapy criteria for Durolane. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the physical therapy services (97110, 
97161, 97112, 97530) provided from January 4, 2022, to March 1, 2022. 
 
You asked the Plan to waive the copayments for physical therapy. You say that this therapy was related to 
COVID-19, which you contracted in December 2020, so these copayments should be waived. The Plan denied 
your request. The Plan says these claims were processed correctly, and your cost-sharing was assessed in 
accordance with 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 $35 
copayment for each outpatient rehabilitation therapy visit.  
 
You have been asked to pay a $35 copayment for physical therapy. Physical therapy falls within the outpatient 
rehabilitation therapy 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 waive the copayments for the 
physical therapy services (97110, 97161, 97112, 97530) provided from January 4, 2022, to March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99232) provided on January 30, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is included 
in the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery  
 We looked at the file and Medicare rules. Payment for the requested services is included in the global surgery 
payment for the procedure (22612, 63047) performed on January 31, 2022. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the services (99232) provided on January 30, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation services 
(A0427, A0425) provided on February 7, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that this was not a far 
ambulance ride, and you feel this copayment is unreasonable for the services provided. The Plan denied your 
request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance 
with 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 $200 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $200 copayment for the ambulance transportation. 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 ambulance transportation services (A0427, A0425) provided on February 7, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac monitoring services provided on January 10, 
2022, and January 17, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the cardiac monitoring services. You say that you want these services covered. 
The Plan denied your request. The Plan says a prior authorization is required for all non-contracted providers. 
 
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 remote cardiac monitoring services provided 
on January 10, 2022, and January 17, 2022, by an out-of-network provider.