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

 
We decided that the Plan does not have to pre-approve Supartz FX for the enrollee. 
 
You asked the Plan to pre-approve Supartz FX. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says that the enrollee does not have any stated contraindications to the preferred 
products. 
 
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 Supartz FX. Our reviewer says that 
Supartz FX is not medically reasonable and necessary. The Plan requires a trial of Orthovisc, Synvisc, or 
Synvisc-One before they will approve the requested drug. In this case, the patient has not tried and failed the 
required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the 
enrollee's condition does not meet step therapy criteria for Supartz FX. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with 
electrocardiographic (EKG) recording with real-time analysis. 
 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that real-time EKG monitoring is covered when specific 
criteria are met. 
 
We looked at the file and Medicare rules. The file does not contain documentation to support that the criteria 
for coverage are met. It is noted that the Plan made multiple attempts to obtain documentation from the 
participating provider for these services. 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 
external mobile cardiovascular telemetry with electrocardiographic (EKG) recording with real-time analysis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 17, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the laboratory testing was ordered by the 
referring provider, and you would like reconsideration for the claim to be paid. The Plan denied your request. 
The Plan says the rendering and referring providers are both OON providers and there was not approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 17, 2021, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided September 7, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed".  
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of service in question. 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 drug testing services (G0483) provided September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic testing provided on October 13, 2021. 
 
You asked the Plan to pay for the diagnostic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 
 
 
 
 We find that the diagnostic testing is not supported in the medical record. Specifically, these testing services 
were provided to the enrollee and therefore, should be billed by the facility of where the services were 
rendered. Based on this information, we decided that Medicare rules for coverage of the diagnostic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic testing provided on 
October 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost for inpatient hospital admission provided from 
January 9, 2022, through January 12, 2022, and January 12, 2022, through January 19, 2022. 
  You asked the Plan to reduce the cost for inpatient hospital admissions. You say that it should be counted as 
one admission because it was for the same issue. 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 $490 
copayment for each Medicare covered day for days 1-3; $0 copayment for each additional day after you meet 
your $395 deductible.  
 
You have been asked to pay a total of $3,335 for the inpatient hospital admissions. ($490/per day x 3 days= 
$1,470) ($1,470/stay x 2 stays = $2,940) ($395 deductible + $2,940 = $3,335). The inpatient hospital 
admissions fall 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 reduce the 
cost for inpatient hospital admission provided from January 9, 2022, through January 12, 2022, and January 12, 
2022, through January 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
November 24, 2020, to November 26, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says acute kidney failure, unspecified is not substantiated as a valid diagnosis.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 065. 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 pay for the services. Our reviewer says that the services at issue in this case were not 
supported by the medical records. Our physician reviewer found the reviewed documentation indicates that the 
provider stated in the appeal documents that the creatinine ranged from 1.37 to 1.60 mg/dl during the 
hospitalization. There was no documentation of a baseline creatinine less than 1.37 mg/d. DRG 066: 
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC is the appropriate 
DRG.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from November 24, 2020, to November 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
December 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
December 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency 
transport (A0428). 
 
You asked the Plan to pre-approve non-emergency ambulance service. You say that you need ambulance 
transport. The Plan denied your request. The Plan says the request is not medically necessary because the 
enrollee does not meet the criteria requirements outlined in Medicare rules for this service. 
 
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 pre-approve non-emergency ambulance service. Our 
reviewer says that non-emergency ambulance transportation is not medically necessary. Our physician reviewer 
found the documentation does not support that you need the expertise, services and lifesaving and life-
sustaining equipment that only a fully equipped ambulance can provide for safe transport. You are stable for 
discharge with no documented medical need for life support monitoring during transportation. The 
documentation does not support that the ambulance transport is 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 non-emergency ambulance service have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency transport 
(A0428).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says an intensive rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive orthodontic treatment of the adult dentition 
(8090) provided January 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that payment was sent to the wrong dental company 
and that is why your Invisiline was not covered. You was never told that it was not a covered benefit when you 
was sold the policy by the agent. You were told that Invisiline was covered. The Plan denied your request. The 
Plan says this procedure is not a covered benefit. 
 
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 pay for 
comprehensive orthodontic treatment of the adult dentition (8090) provided January 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there is no documentation supporting 3 times a week physician 
oversight required and care can be rendered at skilled nursing level. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
enrollee is medically stable with no new and acute medical problems and does not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. There are no acute rehab nursing needs identified 
or documented in the record. At the current functional mobility level as described above, the enrollee does not 
need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. IRF admission is not medically necessary based on medical stability, lack 
of medical complexity, and lack of rehab nursing needs. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a face down recovery system provided on December 20, 
2021. 
 
You asked the Plan to pay for a face down recovery system. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says rules for payment for the requested item have 
not been met.  
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say that face down positioning devices are considered "precautionary devices" 
and also can be used for purposes other than the treatment of an illness or injury. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for a face down recovery system provided on December 20, 2021.  
 
Your complaint about receiving erroneous or incomplete information from a representative of the Plan about 
your benefits is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided September 20, 2021.
You asked the Plan to pay for the core buildup. You say that this service was necessary. The Plan denied your request. The Plan says this service is not covered under your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 pay for the core buildup, including any pins when required (D2950) provided September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair with tilt-in-space (E1161) and 
accessories (E2622, E0955, E1028, E2611, E2203, E2311, A9270, K0040, E0951, K0038. E0973, E0971). 
 
You asked the Plan to pre-approve a manual wheelchair with tilt-in-space and accessories. You say that these 
items are medically necessary. The Plan denied your request. The Plan says the enrollee's current wheelchair 
meets the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair with tilt in space (E1161) is 
covered if the beneficiary has had a specialty evaluation that documents the medical necessity for the 
wheelchair and its special features. If the manual wheelchair base is not covered, then related accessories will 
be denied as not 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 a manual wheelchair with tilt-in-space 
and accessories.  Our reviewer says that the requirements for coverage have not been met. Our physician reviewer found there is 
no documentation that the enrollee has had a specialty evaluation supporting the specific requested wheelchair. 
The provided records do not document how the enrollee's current manual wheelchair is inadequate and how the 
tilt-in-space wheelchair will be an improvement compared to the enrollee's current manual wheelchair. 
 
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 manual wheelchair with tilt-in-space and accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair with tilt-in-space 
(E1161) and accessories (E2622, E0955, E1028, E2611, E2203, E2311, A9270, K0040, E0951, K0038. E0973, 
E0971).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on November 
12, 2021, and December 28, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you don't understand why 
drawing blood via a port is considered a procedure rather than a test. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $200 for each outpatient hospital service including labs and diagnostics billed by the hospital.  
 
The enrollee has been asked to pay $267.42 for laboratory services.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
November 12, 2021 Laboratory Service $133.71 $200 $133.71 
November 28, 2021 Laboratory Service $133.71 $200 $133.71 
TOTAL:    $267.42 
 
The laboratory service falls within the Outpatient hospital services 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 laboratory services provided on November 12, 2021, and December 
28, 2021.