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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
January 11, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that your doctor on duty said 
you needed do go to the emergency room. You say that you waited for a while in the emergency room, and 
they informed you they were unsure of when you would be seen. 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 $90 
copayment for Medicare-covered emergency room visits. (Copay waived if admitted within 24 hours.).  
 
 
 
 You have been asked to pay a $90 copayment for an emergency room visit. The emergency room visit falls 
within the Emergency 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 
emergency room visit provided on January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 22, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the claim reviewed and 
request a retro authorization. The Plan denied your request. The Plan says the rendering provider is an OON 
provider, and the service rendered was not urgent or emergent nor were they 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 laboratory services provided on December 22, 
2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta. 
 
You asked the Plan to pre-approve Neulasta. You say that the requested Neulasta is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Ziextenzo, Fulphila, Nyvepria, or 
Udenyca first. 
 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 Neulasta. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee is receiving the requested drug for febrile neutropenia prophylaxis in the setting of chemotherapy. The 
requested medication is a new start. 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. 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 Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that you require the services on an inpatient basis, only in a skilled nursing facility setting. 
Records do not document that services in the long-term care facility on a part time basis are not appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Airgo Fusion F20 Side-Folding Rollator and 
Transport Chair. 
 
You asked the Plan to pre-approve an Airgo Fusion F20 Side-Folding Rollator and Transport Chair. You say 
that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-
preferred brands). 
 
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 an Airgo Fusion F20 Side-Folding 
Rollator and Transport Chair. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found based on the medical records provided there is no documentation that the plan's preferred 
brands would not be sufficient in meeting your medical needs. Provided records do not document the medical 
necessity of the specific brand of walker and wheelchair requested as opposed to the health plan's preferred 
brands as required in the Medicare guidelines as detailed in the Medicare Managed Care Manual Chapter 4, 
Section 10.12.2. A note in the records reports that home health recommended these requested brands but no 
other supporting documentation to meet Medicare requirements for medical necessity have been provided. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Airgo Fusion F20 Side-Folding Rollator and Transport Chair have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an Airgo Fusion F20 Side-Folding 
Rollator and Transport Chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ViviGen allograft. 
 
You asked the Plan to pre-approve a ViviGen allograft. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a ViviGen allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Vivigen allograft remains experimental for use in spinal surgery. More research is 
needed to show safety and efficacy when used as bone graft material. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ViviGen allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a ViviGen allograft.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of a lower extremity joint. 
 
You asked the Plan to pre-approve an MRI of a lower extremity joint. You say that the services are necessary. 
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
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 an MRI of a lower extremity joint. Our 
reviewer says that the services are medically necessary. Our physician reviewer found you have a history of 
direct trauma to the left hip. You also have significant long term steroid use which predisposes you to avascular 
necrosis (AVN) of the hips and your clinician is concerned about that possibility in light of the recent trauma. 
An MRI is the best imaging test to evaluate for (AVN) of the hips and should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of a lower extremity joint have been met. Therefore, we decided that 
the Plan has to pre-approve a magnetic resonance imaging (MRI) of a lower extremity joint.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 gene analysis. 
 
You asked the Plan to pre-approve BRCA1 and BRCA2 gene analysis. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that BRCA1 and BRCA2 testing are covered by Medicare 
when specific criteria are met. 
 
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 BRCA1 and BRCA2 gene analysis. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found BRCA1 and BRCA2 
is not suspected in enrollees with endometrial cancer. Coverage criteria listed in above LCD is not met. The 
service 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 BRCA1 and BRCA2 gene analysis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve BRCA1 and BRCA2 gene analysis.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that the requested Synvisc is medically necessary. The 
Plan denied your request. The Plan says the requested Synvisc is not medically necessary. 
 
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 Synvisc. Our reviewer says that the 
requested Synvisc is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of meniscal tear. The Food and Drug Administration has not stated that the requested 
drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's clinical situation. 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. Specifically, medical records were not provided. Without this 
documentation, medical necessity is not able to be established. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CancerNext-Expanded genetic testing. 
 
You asked the Plan to pre-approve CancerNext-Expanded genetic testing. You say that the requested 
CancerNext-Expanded genetic testing is medically necessary. The Plan denied your request. The Plan says the 
requested CancerNext-Expanded genetic testing 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 CancerNext-Expanded genetic testing. 
Our reviewer says that the requested CancerNext-Expanded genetic testing is not medically necessary. Our 
physician reviewer found the enrollee does not meet National Comprehensive Cancer Network (NCCN) 
Guidelines for genetic testing for breast cancer based on diagnosis of an estrogen positive ductal carcinoma in 
situ (DCIS) diagnosed in her 60s and 1 close relative with breast cancer in her 50s to early 60s. The service 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 CancerNext-Expanded genetic testing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve CancerNext-Expanded genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on January 19, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a home health visit. You say that the physician provided treatment to the enrollee 
in good faith, and you would like the claim reprocessed. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no authorization obtained prior to the service being 
rendered. 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 a home health visit provided on January 19, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total thyroidectomy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a total thyroidectomy to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a total thyroidectomy to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
August 7, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you had bleeding from 
the first procedure and was directed to another hospital. You also say that all you wanted was a basic 
colonoscopy that would not cost you anything. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for outpatient surgery at an outpatient hospital.  
 
The record shows this claim was approved, and you have a cost sharing amount. A diagnostic colonoscopy is 
not considered a preventive screening. You have been asked to pay a $200 copayment for a diagnostic 
colonoscopy. A diagnostic colonoscopy 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 diagnostic colonoscopy provided on August 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract eye surgery and associated procedures to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve cataract eye surgery and associated procedures to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
cataract eye surgery and associated procedures to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for radiation therapy provided from February 
1, 2022, to February 14, 2022.  
 
You asked the Plan to reduce the copayment for radiation therapy. You say that you should only be charge one 
copayment for the total therapy. 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 $60 
copayment for in-network radiation therapy services.  
 
The record shows this claim was approved, and you have a cost sharing amount for each radiation therapy 
service. You have been asked to pay a $60 copayment for 10 radiation therapy visits from February 1, 2022, to February 14, 2022.You have been asked to pay a total of $600 ($60 copayment x 10 visits = $600). Radiation 
therapy 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 radiation therapy provided from February 1, 2022, to 
February 14, 2022.