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

We decided that the Plan does not have to waive the copayment for arthroplasty of the knee (27447) rendered
on September 14, 2021.
You asked the Plan to waive the copayment for arthroplasty of the knee. You say that you are being billed for a
surgery you never ha on that date. You also say that the only thing they did was numb your leg and give you an
epidural, but since your blood pressure was too high, they could not do the surgery. The Plan denied your
request. The Plan says according to the record, the procedure was cancelled after the administration of amnesia,
therefore, 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 $400
copayment for outpatient surgery in an outpatient hospital facility.
You have been asked to pay a $400 copayment for arthroplasty of the knee. Arthroplasty of the knee falls
within the outpatient surgery included services provided at hospital outpatient facilities and ambulatory surgical
centers 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 arthroplasty of the knee (27447)
rendered on September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and
two or more power seating system motors, (E2311) prefabricated joystick handles that have shapes other than a
straight stick (E2323).
You asked the Plan to pre-approve the upgraded electronics. You say that you are providing the enrollee with a
K0835, group 2 with rehab style frame, with power tilt, as a supplier elected upgrade from the K0836. The Plan
denied your request. The Plan says upgrades in the electronic controllers of the wheelchair are not medically
necessary if hand dexterity and strength is adequate, as each component has its own controller.
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 the upgraded electronics. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the requested items exceed the enrollee's medical need. The enrollee has 2 power
options on the approved wheelchair but the enrollee's upper extremity function with independence in eating,
typing and writing supports that the enrollee can control any power options through their own switches. The
enrollee does not require other proportional input (i.e. touchpads) or non-proportional input devices (e.g., sip
and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices),
other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive
control), or an attendant control.
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 upgraded electronics have not been met. Therefore, we decided that the Plan
does not have to pre-approve electronic connection between wheelchair controller and two or more power
seating system motors, (E2311) prefabricated joystick handles that have shapes other than a straight stick
(E2323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a gym membership provided on October 18, 2021.
You asked the Plan to reimburse you for the gym membership. You say that you were under the impression
since you paid $25 over the phone that you would be able to utilize the coverage immediately. The Plan denied
your request. The Plan says the coverage was not effective until October 25, 2021.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The Plan's rules for coverage of gym benefits have not been met. Therefore, we decided that the Plan does not
have to reimburse you for a gym membership provided on October 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spravato 84mg nasal spray for the enrollee.
You asked the Plan to pre-approve the spray. You say that this is medically necessary. The Plan denied your
request. The Plan says this is a nasal spray medication that is self-administered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 Spravato 84mg nasal spray for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on August 26, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were misdiagnosed and given medication that did not work. The Plan denied your request. The Plan says you have been 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 $65 copayment for urgent care services. The file shows that services were rendered and an official diagnosis of pharyngitis was made. Therefore, you have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the Urgently
Needed 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 copayment for an urgent care visit provided on August 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Budesonide caplet 3mg DR for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this self-administered drug does not fall under Part B benefits.
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 Budesonide caplet 3mg DR 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 the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary. The Plan states the enrollee is receiving the care they need in the hospital where they are now and there is no need to transfer to the LTACH at this time. The Plan states the enrollee can stay in the hospital until they are safe for transfer or discharge.
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 was admitted with acute hypoxic respiratory failure from Coronavirus (COVID-19) pneumonia. The record indicates that the enrollee requires dialysis and requires high flow oxygen. The record indicates that the enrollee requires ongoing acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
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 enrollee needs an IRF admission. The Plan
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF.
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 the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multidisciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a second sterilized compression wrap (E0673) provided to the enrollee on February 4, 2021.

You asked the Plan to pay for the second wrap. You say that these are a set with two separate wraps that are both used during surgery. The Plan denied your request. The Plan says this is a duplicate claim.

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 E0673 is "Segmental gradient pressure pneumatic appliance, half leg." 

We find that the second reporting of E0673 is not supported in the medical record. Specifically, this code was not billed a valid modifier to show that it was being repeated, and is a distinct service. Based on this information, we decided that Medicare rules for coverage of the second wrap have not been met. Therefore, we decided that the Plan does not have to pay for a second sterilized compression wrap (E0673) provided to the enrollee on February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265).
You asked the Plan to pre-approve the total electric hospital bed. You say that you need a bariatric bed in which you can obtain your occupational and physical therapy per your therapists and your primary care physician. You state you currently have a regular house bed with memory foam. The Plan denied your request. The Plan says the total electric hospital bed is not covered by Medicare or your health plan.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the total electric hospital bed have not been met. The rules say a total electric hospital bed (E0265) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for preventative medicine individual counseling (99401) non-covered item or service (A9270) unclassified drugs (J3490) provided April 5, 2021 to August 23, 2021.
You asked the Plan to pay for the weight loss program. You say that you were recently informed that your insurance would pay for a weight loss program. You have enclosed completed claim forms for your weight program. You are still going and will not exceed 22 visits. The Plan denied your request. The Plan says the provider is not credentialed, and the codes used are not Medicare covered codes.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. The billed codes are also not valid Medicare covered codes. Therefore, we decided that the Plan does not have to pay for preventative medicine individual counseling (99401) non-covered item or service (A9270) unclassified drugs (J3490) provided April 5, 2021 to August 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for professional drug infusion services (G0069) provided on
August 31, 2021.
You asked the Plan to pay for professional drug infusion services. You say that you would like this claim
reprocessed based on the medical documentation. The Plan denied your request. The Plan says the records do
not support the services billed.
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 G0069 is professional services for the administration of
subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug
administration calendar day in the individual's home, each 15 minutes.
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 professional drug infusion services. Our reviewer says that
the documentation does not support the services as billed. Our reviewer found the medical records indicate that
the scheduled infusion did not occur on August 31, 2021 and was rescheduled.
Therefore, this service cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of professional drug infusion services have not been met. Therefore, we decided
that the Plan does not have to pay for professional drug infusion services (G0069) provided on August 31,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex device placement surgery for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee is a good candidate for this
procedure. The Plan denied your request. The Plan says that unproven and not medically necessary procedures
are not covered by Medicare due to insufficient evidence of efficacy.
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. The vertiflex device
is experimental. More research is needed. 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 Vertiflex device placement surgery for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Simponi Aria.
You asked the Plan to pre-approve Simponi Aria. You say that you are requesting approval for Simponi Aria.
The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the
Plan requires a trial of Humira, Enbrel, Xeljanz, or Rinvoq before it will approve Simponi Aria.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. Medicare covers Part B medications when they are reasonable and necessary but allows health plans
to implement step therapy criteria.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Evidence of Coverage submitted by the Plan does not specify that step
therapy criteria have been implemented that are applicable to Simponi Aria. Although the Plan did submit a
Medicare Part B preferred drug list, the enrollee's contract with the Plan does not support that the enrollee is
contractually obligated to try a preferred drug before using a non-preferred drug such as Simponi Aria. The
Plan did not provide any other evidence or rationale to support a denial of authorization for Simponi Aria.
Therefore, the Plan has not shown that its decision to deny authorization for Simponi Aria is correct or justified
according to Medicare rules or the enrollee's contract with the Plan. Therefore, we decided that the Plan has to
pre-approve use of Simponi Aria.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cuvitru.
You asked the Plan to pre-approve Cuvitru. You say that this is medically necessary. The Plan denied your
request. The Plan says that you do not have any stated contraindications to the preferred products.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Cuvitru. Our reviewer says that Cuvitru
is not medically reasonable and necessary. You have not tried and failed Hizentra or Privigen. There is no
indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for
you. Our physician reviewer found that your condition does not meet step therapy criteria for Cuvitru.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Cuvitru have not been met. Therefore, we decided that the Plan does not have to
pre-approve Cuvitru.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Test Strips 100 per 33.
You asked the Plan to pre-approve the strips. You say that the strips are necessary. The Plan denied your request. The Plan says in order to get the non-preferred diabetic supply, you can have your doctor send in a request for this supply as DME. The Plan states the quantity requested exceeds the number Medicare considers 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 strips. Our physician reviewer found the record indicates that the enrollee has diabetes. The record provided is insufficient to establish the need for non-preferred test strips as requested. The elements of the coverage criteria are not satisfied. The requested service is not 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 strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Test Strips 100 per 33.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on August 18, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. 

We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on August 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve Intracept. You say that Intracept is medically necessary for the enrollee. The
Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies
have not proven that this is helpful for treatment of the enrollee's condition.
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 Intracept. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this is considered an experimental/investigational procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Intracept procedure.