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

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. The Plan denied your request. The Plan says medication must be 
furnished by the physician. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Monovisc.  
 
Benefits for Monovisc 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
  You asked the Plan to pre-approve the SNF admission. You say that your family cannot take care of you in the 
state that you are currently in, and going to a SNF will help teach your family on how to take care of you when 
you come home. You also say that your family fears something will happen to you in the environment you are 
currently in. The Plan denied your request. The Plan says your request for an admission to a SNF does not meet 
the requirements for approval. 
 
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 the SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit provided on 
September 5, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that this should be covered because the 
enrollee was brought to the hospital after a car accident. You said that the enrollee was in the room for 30-40 
minutes before being seen and no services were provided. The Plan denied your request. The Plan says this 
copayment was charged correctly. 
 
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 $110 copayment for emergency room visits.  
 
The enrollee has been asked to pay a $110 copayment for the ER visit. This copayment applies regardless of the reason for the ER visit and regardless of the extent of services received in the ER. 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 the emergency room (ER) visit provided on September 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission 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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy 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 
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the durable medical equipment provided 
from April 27, 2021, to June 27, 2021. 
 
You asked the Plan to waive the cost share for the services provided. You say that you were forced to wear the 
vest. The Plan denied your request. The Plan says the claim processed correctly. 
 
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% of 
the cost for durable medical equipment.  
 
The file shows that you were provided with an external automatic external defibrillator for 3 months. For 2 
months, you were charged $700, which is 20% of the total cost. For the third month, you were charged $317.76 
because you met your out-of-pocket maximum. The services fall within the durable medical equipment 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 cost share for the durable medical equipment provided from 
April 27, 2021, to June 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found there is no documentation provided to support the expectation that you will require a 
greater than two midnight stay.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Specifically, the approved 
surgery can be obtained in an observational level of care. This means admission into an inpatient hospital is not 
medically necessary. Therefore, we decided that the Plan does not have to pay for acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that you need this dental item. The Plan denied 
your request. The Plan says complete upper denture is not listed as a covered service. 
 
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 complete upper denture 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve a complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the enrollee was a patient prior to switching 
plans and would like to continue to see the same provider. The Plan denied your request. The Plan says the 
provider is an out-of-network provider and the services provided are not urgent or emergent. Also, a list of in-
network providers was given to the enrollee that provide the same quality of service. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) four all 
four quadrants. 
 
You asked the Plan to pre-approve scaling and root planing. You say that these services are necessary. The 
Plan denied your request. The Plan says these services are not covered by the plan's 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 
periodontal scaling and root planing (D4341) four all four quadrants.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Onpattro for the enrollee. 
 
You asked the Plan to pre-approve Onpattro. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of Onpattro in the setting of non-hereditary 
transthyretin-mediated amyloidosis has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for 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 Onpattro. Our reviewer says that 
Onpattro is not medically reasonable and necessary. Onpattro is being requested in the setting of non-
hereditary, transthyretin-mediated amyloidosis with cardiomyopathy. The FDA has recently approved the use 
of Onpattro for the treatment of the polyneuropathy of hereditary, transthyretin-mediated amyloidosis. At this 
time, there is inadequate clinical evidence to support its role in this patient's clinical management. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of Onpattro. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Onpattro have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Onpattro for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient physical therapy (PT) services to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient PT services. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says there are in network providers that are available. 
 
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 
outpatient physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on November 9, 2021. 
 
You asked the Plan to pay for the dental service. You say that you would not have gotten x-rays if you had 
known they would not be covered. You also say that an exception should be made, and the service be covered. 
The Plan denied your request. The Plan says dental x-rays are covered for 1 visit every year. 
 
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 and dental x-rays are listed as covered, 
the frequency limit of 1 visit every year has been exceeded. The record shows that the Plan paid for x-rays that 
you received on February 18, 2021. Therefore, we decided that the Plan does not have to pay for the bitewing 
x-rays (D0274) provided on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 6, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services provided should not require an 
authorization and the claim should be paid. The Plan denied your request. The Plan says the provider is an out-
of-network provider and there was no approved authorization. Also, the services provided 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 laboratory services provided on April 6, 2021, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the positron emission tomography (PET) 
scan you had on October 22, 2021. 
 
You asked the Plan to waive the copayment for the PET scan. You say that you were not aware of the 
copayment being this high and you cannot afford this.  You said that had you known about the copayment, you 
would have declined the service. The Plan denied your request. The Plan says you were charged this 
copayment correctly. 
 
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 $250 
copayment for diagnostic radiology services (other than ultrasounds).  
 
You have been asked to pay a $250 copayment for the PET scan. The PET scan falls within the diagnostic radiology services (other than ultrasounds) 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 positron emission tomography (PET) scan you had on October 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the breast ultrasound you had on June 10, 
2021. 
 
You asked the Plan to waive the coinsurance for the breast ultrasound. You say that this should be covered in 
full because the mammogram you had was a screening. The Plan denied your request. The Plan says you were 
charged this coinsurance correctly. 
 
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 up to $75 per day for diagnostic radiology services.  
 
 You have been asked to pay 20% coinsurance up to $75 per day for the breast ultrasound. This coinsurance is 
being charged because you had an ultrasound, not because of any mammogram you may have had. The breast 
ultrasound falls within the diagnostic radiology services 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 the breast ultrasound you had on June 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) with 3D 
imaging. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the imaging. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has no 
findings in her history of on exam that would otherwise generally prompt the need for performance of CTA of 
the head. Such studies are not generally recommended for use in these conditions/complaints. They are 
primarily for evaluation of neurovascular disorders --most of which may necessitate surgical intervention. The 
information in this case does not show any family history or similar findings that would otherwise prompt such 
testing. Therefore this service cannot be determined to be 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 the imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography angiography (CTA) with 3D imaging.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
  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 
Injectafer is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. 
Our reviewer found that the record does not indicate that the enrollee has a contraindication to, or would have 
an adverse effect from the Plan's preferred step one alternative. Our physician reviewer also found that the 
elements of the coverage criteria are not satisfied and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).