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

 
We decided that the Plan does not have to pre-approve Supartz injections (J7321). 
 
You asked the Plan to pre-approve Supartz. You say that Supartz is medically necessary. The Plan denied your 
request. The Plan says a trial of  Synvisc, Orthovisc, and Monovisc is required before alternatives can be 
considered. 
 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 Supartz. Our reviewer says that Supartz 
is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred 
drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz injections (J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the oxygen concentrator provided on 
January 19, 2021. 
 
You asked the Plan to waive the deductible for the oxygen concentrator. You say that the cost of the machine is 
a burden on yourself and your family but its medically necessary. The Plan denied your request. The Plan says 
the deductible was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan clearly says that there is a $250 deductible that applies to out-of-network services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Durable medical equipment 
(DME) and related supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $250 deductible that applies to the oxygen concentrator. This cost sharing is a 
contractual obligation that had not been met at the time the oxygen concentrator was received on January 19, 
2021. Therefore, we decided that the Plan does not have to waive the deductible for the oxygen concentrator 
provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient treatment provided on September 13, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient treatment. You say that you received an approved authorization, 
but it was for a different code. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered 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 the outpatient treatment provided on September 
13, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting acute inpatient rehab versus a 
lower level of care because she requires 3 hours of care per day provided by a multidisciplinary team to return 
to her prior level of function. You say that she meets the full criteria for an acute inpatient rehab stay and a 
lower level of care cannot provide what is necessary to keep her healthy and safe. The Plan denied your 
request. The Plan says the service is not medically necessary for the enrollee's condition.  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 the enrollee does not need close supervision 3 times per week and there were no 
rehab nursing needs identified or documented in the record. The enrollee's rehab needs can be met in an 
alternate and lower setting such as a skilled nursing facility. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Left L2 - L5 Facet Joint Radiofrequency Ablation 
 
You asked the Plan to pre-approve the surgical procedure. You say that the continued denial and inability to 
perform this treatment could result in worsening disability and escalation of medication opioid doses to manage 
pain, which you would like to avoid. The Plan denied your request. The Plan says the requested procedure is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a lack of imaging to rule out other sources of pain and the request is for 3 
levels which exceeds utilization criteria which limits RFA to 2 levels at a session. Therefore, the request 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Left L2 - L5 Facet Joint Radiofrequency Ablation
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scans provided on August 4, 2021, 
and August 23, 2021. 
 
You asked the Plan to waive the copayment for the CT scans. You say that you would like the charges covered. 
The Plan denied your request. The Plan says the copayment applied 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 $175 
copayment for CT scans.  
 
 
 
 
 
 
 
 You have been asked to pay a total of $350 ($175 x 2 scans = $350). CT scans fall 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 CT scans provided on August 4, 2021, and August 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin 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 the requested Avastin is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that 
the enrollee has a diagnosis of non-exudative age related macular degeneration. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. The elements of the coverage criteria are not satisfied. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Avastin for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Pathology services provided on June 16, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Pathology services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for 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 Pathology services provided on June 16, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blood pressure monitor (E1399). 
 
You asked the Plan to pre-approve a blood pressure monitor. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says this item is not covered. 
 The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a blood pressure monitor (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that this is a Medicare-covered service. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20mg Latuda tablets. 
 
You asked the Plan to pre-approve the Latuda tablets. You say that you would like reconsideration because the 
requested drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered 
under Medicare Part B. 
 
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 20mg Latuda tablets.  
 
Benefits for the Latuda tablets 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve the portable ventilator. You say that this device is medically necessary. The 
Plan denied your request. The Plan says a bi-level PAP device meets the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that products currently classified with codes E0465, 
E0466, or E0467 when used to provide CPAP or bi-level PAP (with or without backup rate) therapy, regardless 
of the underlying medical condition, shall not be paid. 
 
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 portable ventilator. Our reviewer 
says that the portable ventilator is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record 
indicates that the requested device is being used in the BiPAP-AVAPS mode. The requested device is excluded 
by coverage rules. 
 
 
 
 
 
 
 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical stimulator placement (64590). 
 
You asked the Plan to pre-approve the electrical stimulator placement. You say that this device is medically 
necessary. The Plan denied your request. The Plan says the requested device is considered an electro-
acupuncture device and is not covered under the requested code. This device is not implanted in an operating 
room. Records provided do not support acupuncture service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers should not be using code 64590 to 
describe a Percutaneous Electrical Nerve Stimulation (PENS) device, as this code is for a neurostimulator pulse 
generator or receiver implantation. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the electrical stimulator placement have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electrical stimulator placement (64590).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the ferric carboxymaltose injection, and IV 
infusion provided on November 1, 2021.You asked the Plan to waive the cost share for Part B drugs. You say 
that these services should be covered. The Plan denied your request. The Plan says the cost share applied 
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 for each ferric carboxymaltose injection and a $295 copayment for the intravenous infusion.  
 
You have been asked to pay a total of $302.85 for the ferric carboxymaltose injection and IV infusion.  
 
Date Of Service Service Allowed Amount Standard Cost Member Liability 
November 1, 2021 96365-Intravenous 
Infusion 
$180 $295 $180 
November 1, 2021 J1439- Ferric 
Carboxymaltose  
Injection 
$614.25 20% $122.85 
TOTAL:    $302.85 
 
The ferric carboxymaltose injection falls within the Medicare Part B Prescription Drugs benefit category. 
The IV infusion falls within the Outpatient Surgery and Other Medical 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 cost share for the ferric carboxymaltose injection, and IV infusion provided on November 1, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you have two broken feet, and your mouth is wired 
shut. You say that you live alone and cannot take care of yourself at this time. The Plan denied your request. 
The Plan says that you do not meet criteria for SNF care. 
 
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 you 
qualify for SNF coverage due to having documented skilled therapy needs. Our physician reviewer found that 
given your oral/verbal limitations and weight bearing restriction, you are in need if strength, endurance and 
activities of daily living training. Daily skilled services are reasonably required to establish a maintenance 
program and/or to prevent deterioration of your condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
  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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 13, 2021.