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

 
We decided that the Plan does not have to waive the copayment for the scanning of computerized ophthalmic 
diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134) 
provided from March 14, 2021, to November 17, 2021. 
 
You asked the Plan to waive the copayment for the scanning of computerized ophthalmic diagnostic imaging, 
posterior segment, with interpretation and report, unilateral or bilateral; retina. You say that doctors, specialists, 
keep charging $30 when your copayment says $25. You also say that you are 79 years old, living on a tight 
budget and every $5 adds up. The Plan denied your request. The Plan says you were 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 $30 
copayment for Medicare-covered non-radiological diagnostic services.   
You have been asked to pay a $30 copayment for the scanning of computerized ophthalmic diagnostic imaging, 
posterior segment, with interpretation and report, unilateral or bilateral; retina. The scanning of computerized 
ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina 
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 waive the copayment for the scanning of computerized ophthalmic diagnostic 
imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134) provided from 
March 14, 2021, to November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services (80053, 85027) 
provided on August 2, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has 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 $10 per 
day for other Medicare-covered laboratory tests that are not fecal immunochemical tests (FIT).  
 
 You have been asked to pay a $10 copayment for the Medicare-covered laboratory tests 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 copayment for the laboratory services (80053, 85027) provided on August 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Ferrlecit, Sodium Ferric Gluconate, 
Infed, or Venofer 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 Injectafer. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records 
provided the enrollee has not tried and failed the required drug(s). There is no indication that the Plan's required 
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (93306), and 
myocardial perfusion imaging (78452). 
 
You asked the Plan to pre-approve transthoracic echocardiography, and myocardial perfusion imaging. You say 
that the requested services are needed. The Plan denied your request. The Plan says in the absence of medical 
records, the services at issue are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of transthoracic echocardiography 
(93306), and myocardial perfusion imaging (78452) have been met. There are no medical records within the 
casefile. Without the requested clinical information, we are unable to determine if the requested services are 
medically necessary. Therefore, we decided that the Plan does not have to pre-approve transthoracic 
echocardiography (93306), and myocardial perfusion imaging (78452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that there is no in=network 
provider that can provide this specific pneumatic compression device, and you can service the member upon 
approval. The Plan denied your request. The Plan says the requested out-of-network provider is not contracted 
in the member's network, and the service is available in-network. 
 
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 pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from September 21, 2021, through 
October 20, 2021. 
  You asked the Plan to pay for SNF services. You say that the services the enrollee received are covered under 
the Medicare Act. The Plan denied your request. The Plan says the member had no skilled therapy or skilled 
nursing service needs. 
 
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 pay for SNF services. Our reviewer says that daily 
skilled services were not necessary. Our physician reviewer found that the enrollee was medically stable 
without any acute exacerbations of chronic medical problems. Her physical function was at or near her baseline 
and admission to the nursing facility at a skilled level of care was not 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pay for SNF services provided from September 21, 2021, through October 20, 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 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 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 IRF admission is not medically necessary based on medical stability, medical 
complexity, and lack of rehabilitation nursing needs. Documentation does not support the necessity for 
admission to an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has esophageal cancer and 
iron deficiency anemia with intolerance or unsatisfactory response to oral iron replacement. He has not tried 
and failed the Plan's required drugs, Infed and Venofer. The records do not show that the required drugs would 
be contraindicated or less effective; therefore, Injectafer 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you just had total knee replacement making it 
hard to stand in the shower, and this will help prevent falls in the future. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
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 home with home health care or in a 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 pair custom orthotics, 2 pair custom modified shoes, 
and podiatry services to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve 2 pair custom orthotics, 2 pair custom modified shoes, and podiatry 
services. You say that you have seen 3 Plan podiatrists regarding foot pain in regular shoes from 2015-2021, 
and the only solution they offered you was custom cork orthotics. You also say you tried the cord orthotics in 
2015 and within 2 weeks you were unable to walk without severe pain. The Plan denied your request. The Plan 
says podiatry services are available with Plan providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
2 pair custom orthotics, 2 pair custom modified shoes, and podiatry services 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 pre-approve physical therapy. 
 
You asked the Plan to pre-approve physical therapy. You say that additional physical therapy sessions are 
needed. The Plan denied your request. The Plan says additional physical therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found there is no documentation of a recent injury or decline in function. 
The additional therapy services are not an appropriate duration and frequency for treatment of the members 
medical condition and therefore are not 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 2.5 mg tablet. 
 
You asked the Plan to pre-approve Eliquis. You say that this drug is medically reasonable and necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's 
medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis 2.5 mg tablet.  
 Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
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 the IRF services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 there is not a reasonable expectation that this patient will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says your records received do not indicate that you have an 
emergent or urgent medical condition, or are in need of specialized services that are not available in the 
network. The Plan also says there are in-network providers within a reasonable distance from your location that 
can provide this service or item. 
 
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 specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81551) provided December 9, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that that ConfirmMMDx is covered for males aged 
40 to 85 years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are 
being considered for a repeat biopsy. 
 
We looked at the file and Medicare rules. The record shows no previous negative biopsy. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (81551) provided December 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on November 6, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says services were rendered by a non-participating provider on 
November 6, 2021, and the services rendered were not authorized by the Plan and we not referred by a 
participating provider. 
 
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 physical therapy services provided on November 
6, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic imaging procedures of the chest provided on 
August 29, 2021. 
 
You asked the Plan to pay for diagnostic imaging procedures of the chest. The Plan denied your request. The 
Plan says with the information we have, we cannot determine how the member came to the servicing provider, 
or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of diagnostic imaging procedures of the 
chest provided on August 29, 2021. have been met. Therefore, we decided that the Plan does not have to pay 
for diagnostic imaging procedures of the chest provided on August 29, 2021.