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

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on August 26, 
2021. 
 
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 medication wastage is not documented in the medical records; therefore, J9299-JG,JW X 80 
units 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 J9299 is "Injection, nivolumab, 1 mg." 
 We asked our coder 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 reviewer found that the procedure report does not 
include documentation of discarded drugs and biologicals. 
 
We looked at this coder's review, the file, and Medicare rules. 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 injection services provided to the enrollee on August 26, 2021.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that documentation does not support that your functional status requires 3 
hours of therapy a day. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and near syncope. 
Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that your 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a spinal cord stimulator. 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that your back issues are affecting your legs 
and your quality of life has decreased. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because you had a failed trial of a stimulator in the same area in 2021. 
 
The Plan follows Medicare rules. Medicare rules state that a spinal cord stimulator is only covered if certain 
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 spinal cord stimulator. Our reviewer says that you do not meet the Medicare criteria for a spinal cord stimulator. Our physician reviewer found you 
failed a prior trial of a spinal cord stimulator. There is no medical literature that suggests if a patient fails a 
spinal cord stimulator trial that the patient will likely benefit from this. This is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of a spinal cord stimulator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has 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 an MRI of the lumbar spine is 
medically necessary. The Plan denied your request. The Plan says that an MRI of the lumbar spine is not 
medically necessary. 
 
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 the lumbar spine. Our 
reviewer says that the requested MRI of the lumbar spine is medically reasonable and necessary. Our physician 
reviewer found that the enrollees symptoms have been described as worsening since her last MRI. She has 
been on oral steroids and Gabapentin without significant relief. The enrollees neurosurgeon is planning 
surgery and needs an updated MRI for surgical planning. It is a reasonable request since the enrollees 
symptoms have been worsening and a repeat study will be needed for surgical planning. 
 
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 the lumbar spine have been met. Therefore, we decided that the Plan 
has to pre-approve an MRI of the lumbar spine.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on July 30, 2021. 
 
You asked the Plan to pay for the medical services. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says the enrollee was on hospice on the date of service in 
question. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says you do not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the occupational therapy evaluation 
(97166), therapeutic exercises (97110), manual therapy techniques (97140), and the whirlpool therapy (97022) 
provided from June 2, 2021, through August 4, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $40 
copayment for physical and occupational therapy provided at an in-network outpatient hospital.    
  
You have been asked to pay $720 ($40 copayment x 58 sessions) for the physical and occupational therapy 
services rendered at an in-network outpatient hospital. Your copayment liability is less than the total of the 
applicable copayments for these services provided. 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 occupational therapy evaluation (97166), therapeutic exercises (97110), manual therapy techniques 
(97140), and the whirlpool therapy (97022) provided from June 2, 2021, through August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN). 
 You asked the Plan to pre-approve parenteral nutrition. You say that the requested IDPN is medically 
necessary. The Plan denied your request. The Plan says the requested IDPN is not reasonable and 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 parenteral nutrition. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found records do not document the enrollee has a permanent impairment involving the 
small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients or a disease of 
the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to be transported 
through and absorbed by the gastrointestinal (GI) system as required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of parenteral nutrition have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intradialytic parenteral nutrition (IDPN).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OnabotulinumtoxinA (J0585). 
 
You asked the Plan to pre-approve OnabotulinumtoxinA. You say that you need to have this procedure done 
due to your medical condition. The Plan denied your request. The Plan says the records do not show that you 
have failed or cannot take an anticholinergic medication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for Food and 
Drug Administration (FDA) approved drugs if they are medically accepted as safe and effective or appropriate 
for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve OnabotulinumtoxinA. Our reviewer 
says that OnabotulinumtoxinA is not medically reasonable and necessary. Our physician reviewer found the 
record indicates that you have a diagnosis of mixed urinary incontinence. Our reviewer found that the FDA has 
not stated that the requested drug is indicated for your condition. Our physician reviewer also found that the 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in 
your clinical situation. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OnabotulinumtoxinA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve OnabotulinumtoxinA (J0585).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the rituximab injection (J9312), the 
bendamustine hcl (bendeka) injection (J9034), the ondansetron injection (J2405), and the diphenhydramine 
injection (J1200) provided on March 3, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the items provided. 
 
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 20% coinsurance for Medicare-covered Part B chemotherapy drugs and other Part B drugs.  
 
 The enrollee has been asked to pay $2,617 (Plan allowed amount of $13,085 x 20% coinsurance) for the 
Medicare Part B drug injections provided. 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 coinsurance for 
the rituximab injection (J9312), the bendamustine hcl (bendeka) injection (J9034), the ondansetron injection 
(J2405), and the diphenhydramine injection (J1200) provided on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options 
 
You asked the Plan to pre-approve a power wheelchair with multiple power options. You say that the enrollee 
needs a wheelchair. He is bedridden and has no use of his hands. The enrollee goes to dialysis and needs to be 
lifted. The Plan denied your request. The Plan says the enrollee resides in a skilled nursing facility. Medicare 
only covers DME for use in the home. Medicare does not cover DME in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power wheelchair with multiple power options is being requested for use in a SNF or 
hospital. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with 
multiple power options
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) services. 
 You asked the Plan to pre-approve MRA services. You say that the records provided support the need for MRA 
services. The Plan denied your request. The Plan says the records do not show that the enrollee has signs of a 
transient ischemic attack or mini-stroke. The Plan says that the records do not show exam results that included 
a detailed nervous system exam that supports imaging. 
 
The Plan follows Medicare rules. Medicare rules say that MRA services are considered medically necessary 
when performed on patients with conditions of the head and neck for which surgery is anticipated and may be 
found to be appropriate based on the MRA. 
 
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 MRA services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee has a remote history of a 
stroke in 1992. There was no indication in the single chart note provided that the enrollee was suspected of 
having any new form of vascular occlusion or thrombosis at this time (for which surgery would be amenable).  
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance angiography (MRA) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facet joint injection provided to the enrollee on June 18, 
2021. 
 
You asked the Plan to pay for the services. You say that Medicare has paid these codes with no issue when 
billed together. The Plan denied your request. The Plan says the requested procedure does not meet the 
guidelines of the appropriate Local Coverage Determination. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found facet injections are indicated when there is absence of untreated radiculopathy or neurogenic 
claudication (except for radiculopathy caused by facet joint synovial cyst).  In this case, the enrollee has 
radiculopathy. The review has determined that the enrollee did not meet the criteria for these injections. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a facet joint injection provided to the enrollee on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite diabetic test strips (A4253).  
You asked the Plan to pre-approve Freestyle Lite strips. You say that the requested items are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MA Plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Freestyle Lite strips have not been met. Specifically, the requested items are a non-preferred brand. 
The case record does document the medical necessity of the requested items. Therefore, we decided that the 
Plan does not have to pre-approve Freestyle Lite diabetic test strips (A4253).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Acupuncture services provided on November 12, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Acupuncture services. You say that that you were misinformed about requiring 
prior authorization. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 Acupuncture services provided on November 12, 
2021 by an out-of-network (OON) provider.