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

 
We decided that the Plan does not have to pay for the x-ray provided on March 15, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that you rely on the hospital staff to obtain all necessary 
paperwork including authorization numbers and referral forms. The Plan denied your request. The Plan says no 
prior authorization was obtained. 
 
 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 did not pre-approve the x-
ray. We found no exception that would require the Plan to pay for the x-ray. The records provided for review 
do not show that the x-ray was urgent or emergent. Therefore, we decided that the Plan does not have to pay for 
the x-ray provided on March 15, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for continuous positive airway pressure 
(CPAP) machine provided from January 12, 2022, to April 11, 2022. 
 
You asked the Plan to waive the coinsurance for CPAP machine. You say that your old machine was recalled, 
and you didn't realize you would have to pay for the new one. The Plan denied your request. The Plan says the 
coinsurance applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for DME and related supplies.  
 
 
 
 
 You have been asked to pay $36.90 which is 20% of the allowed amount for CPAP machine. The allowed 
amount is $184.53 (20% x $184.53= $36.90). CPAP machine falls within the Durable Medical Equipment 
(DME) and Related 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 waive the coinsurance for CPAP 
machine provided from January 12, 2022, to April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that this is necessary for your condition. 
The Plan denied your request. The Plan says this equipment is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 29, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. 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 laboratory services 
provided on March 29, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of Bilateral primary osteoarthritis of the knees. The documentation does not 
support that the enrollee has tried and failed Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. The 
documentation does not support that Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One would likely 
be less effective, and/or would likely have adverse effects for the enrollee 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on January 31, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you chose 
not to be transported by the ambulance, knowing you could call 911 again if you needed to. The Plan denied 
your request. The Plan says you were not transported to an emergency facility. 
 
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 January 31, 2022. 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 January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056) and abutment 
supported crowns (D6059). 
 
You asked the Plan to pre-approve dental implant services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental 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 pre-approve 
prefabricated abutments (D6056) and abutment supported crowns (D6059).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical collar identified with code L0180 provided on 
December 22, 2021. 
 
You asked the Plan to pay for the cervical collar. You say that you feel this item should be covered due to the 
enrollee's past medical history. The Plan denied your request. The Plan says the documentation does not 
support the item rendered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that there is insufficient documentation of a credible physical 
examination of the cervical spine. There is no documentation of trauma to the neck, no documentation of a 
thorough neurologic and strength examination, and no documentation of imaging performed to evaluate the 
cervical spine. There is no mention of a complaint for cervical spine pain or concern by the provider for 
cervical spine pain. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the cervical collar 
identified with code L0180 provided on December 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from January 4, 2022, 
to February 1, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that you were mistreated when you were 
there so you shouldn't have to pay. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $0 
copayment for days 1 through 9, $20 copayment for days 10 through 20 and $155 copayment for days 21 
through 100.  
 
 
 You have been asked to pay $1,460 copayment for SNF care. SNF care falls within the Skilled Nursing Facility 
(SNF) 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 SNF care provided from 
January 4, 2022, to February 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a 
LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care hospital services that can safely be provided at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary at this 
time as it would not be clinically advantageous. Completion of treatment at the current facility is 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861). 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that the requested wheelchair is a 
necessity for your care. The Plan denied your request. The Plan says rules for coverage for the requested PMD 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
  The file does not show that you are able to safely operate the PMD being requested. Specifically, the case 
record includes an occupational therapy evaluation that does not recommend a Group 3 wheelchair for your 
mobility needs. This means that Medicare rules for coverage of the requested power wheelchair have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the enrollee has been a longtime patient of your 
clinic. You also say the primary care provider for this enrollee is a dermatologist in another town. You also say 
that it is unfair for this enrollee to have to travel 20 miles to visit a dermatologist to get primary care. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says 
they have determined that these services are 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 an office visit provided on February 28, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from September 26, 2021, to 
September 29, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care as billed with DRG 871. You say that these services were 
medically necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not appropriate as the diagnoses of sepsis due to methicillin susceptible staphylococcus aureus (A41.01) and 
severe sepsis without septic shock (R65.20) are not supported in the medical record. The Plan argues that DRG 
947 is more appropriate in this case. 
 
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. 
 
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 inpatient care as billed with DRG 871. Our 
reviewer says that the diagnoses of sepsis due to methicillin susceptible staphylococcus aureus (A41.01) and 
severe sepsis without septic shock (R65.20) are not supported in the medical record for this inpatient stay. Our 
physician reviewer found that the emergency department note described the enrollee as non-toxic appearing 
and in no acute distress, with lungs clear to auscultation, normal pulmonary effort, no accessory muscle usage, 
well-nourished, in no respiratory distress, and with no focal neurologic deficits. A chest x-ray showed the lungs 
were hypo inflated but clear with no focal consolidation, effusion, or pneumothorax. The enrollee was 
diagnosed with pancytopenia, alcoholic cirrhosis and hyponatremia and admitted for further care. Treatment 
included intravenous (IV) fluids and IV antibiotics. The review has determined that the medical records do not 
support the billing of sepsis due to methicillin susceptible staphylococcus aureus (A41.01) and severe sepsis 
without septic shock (R65.20). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care as billed with DRG 871 have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital care provided from September 26, 2021, to 
September 29, 2021, as billed with Diagnosis Related Group (DRG) 871.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Infuse BMP-2 Allograft for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Infuse BMP-2 Allograft 
in the setting of posterolateral lumbar spine fusion surgery has not been demonstrated in the peer-reviewed 
literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the enrollee's pathology. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Infuse BMP-2 Allograft for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH care. The Plan denied 
your request. The Plan says the member does not meet the Medicare criteria for admission to an LTACH care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for out of network office visits provided on 
February 12, 2022, and February 21, 2022. 
 
You asked the Plan to waive the deductible for office visits. You say that these visits should be covered. The 
Plan denied your request. The Plan says the deductible applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $600 deductible which applies to Physician/Practitioner Services, 
Including Doctors Office Visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctors Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $600 deductible which applies to Physician/Practitioner Services, 
Including Doctors Office Visits. This cost sharing is a contractual obligation that had not been met at the time 
office visits was received on February 12, 2022, and February 21, 2022. Therefore, we decided that the Plan 
does not have to waive the deductible for out of network office visits provided on February 12, 2022, and 
February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), cervical or thoracic (CPT)code(s): 64492). 
 
You asked the Plan to pre-approve the injection. You say that you previously had facet injections that have 
helped your pain; however, the recent request was denied, and you would like to appeal as you do not agree 
with denial reason. You state that you have an appointment on August 22, 2022. The Plan denied your request. 
The Plan says they are denying approval for the third level as it exceeds the number of injections allowed in a 
12-month rolling period. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our physician reviewer 
found a third level 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint 
(or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic (CPT)code(s): 
64492).