Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy services provided on July 
26, 2021. 
 
You asked the Plan to waive the copayment for the psychotherapy services. You say that you paid for the 
service up front and would like reimbursement from the Plan. 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 $40 
copayment for each mental health visit at a specialist office.  
 
You have been asked to pay a $40 copayment for the psychotherapy services. The file shows that the Plan has 
already reimbursed the Medicare allowable amount directly to you. The psychotherapy services fall within the 
Outpatient Mental Health Care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
psychotherapy services provided on July 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided August 24, 
2021, to September 9, 2021. 
 You asked the Plan to pay for the SNF care. You say that the enrollee required SNF care. The Plan denied your 
request. The Plan says the enrollee has 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 the SNF care. Our reviewer says that daily 
skilled services were not necessary. Our physician reviewer found the enrollee did not have daily skilled 
nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (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 care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided August 24, 2021, to September 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tadalafil for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under 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 Tadalafil for the enrollee.  
 
Benefits for this drug 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 an external speech processor and controller for a 
cochlear implant. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cochlear implant replacement processors are 
covered when 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of bilateral 
cochlear implantation and was evaluated on May 13, 2020, for not being able to use her right cochlear implant. 
The clinical notes indicate that the processors had been "recently replaced due to malfunction." Visits on 
January 29, 2019, and November 4, 2019 showed no technical defects with the devices. The devices were 
inspected, and the right coil was found to be frayed; no other defects were identified, and a coil cable was 
ordered. There is no change in the enrollee's medical condition necessitating a different type of component. The 
documentation does not clearly show that the sound processor or controller had exceeded their reasonable 
useful lifespan; the clinical note dated May 13, 2020, stated that the processors were recently replaced. The 
requested external speech processor and controller for cochlear implant are not reasonable or medically 
necessary at this time. 
 
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 an external speech processor and controller for a cochlear implant.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 a stroke and respiratory failure from aspiration 
pneumonia. The record indicates that the enrollee is unable to follow commands and has copious pulmonary 
secretions. 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 he is 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and surgery provided on May 17, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and surgery. You say that authorization is not required for the 
services provided to the enrollee. The Plan denied your request. The Plan says the rendering provider is an out-
of-network provider and there was no approved authorization. Also, the services 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 an office visit and surgery provided on May 17, 
2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ingressa capsules. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct. 
 
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 Ingressa capsules.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 due to COVID-19 
pneumonia. The enrollee is improving but still requires acute care services and these have not been denied. The 
medical record does not indicate that the enrollee requires services that he is not currently receiving but that 
would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and 
services provided from September 10, 2021, to September 21, 2021. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that you feel this inpatient 
admission could have been prevented, and you have complaints about the care you received in the weeks 
before your admission. The Plan denied your request. The Plan says this claim was processed correctly, and 
your copayment was assessed in accordance with your contract. The Plan also says that your grievance 
regarding quality-of-care concerns is being addressed in a separate case. 
 
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 $290 
copayment for each of the first seven days of an inpatient hospital stay. There is a $0 copayment for each 
additional covered day for each inpatient stay. 
 
 You have been asked to pay a $2,030 copayment for an inpatient admission which lasted longer than seven 
days ($290 x 7 = $2,030). 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 inpatient hospital 
admission and services provided from September 10, 2021, to September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically reasonable and necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic apheresis. 
 
You asked the Plan to pre-approve therapeutic apheresis. You say that this procedure is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure 
is considered experimental/investigational for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say the requested apheresis procedure is covered for the 
indications listed in the Medicare rules section. 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 therapeutic apheresis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case the member does not have a condition for which the NCD supports 
the use of plasmaphersis. Likewise, according to the Guidelines on the Use of Therapeutic Apheresis in 
Clinical Practice  Evidence-Based Approach from the Writing Committee of the American Society for 
Apheresis: The Eighth Special Issue--there is only category III evidence for the "maintenance" use of 
plasmaphersis in multiple sclerosis. It is not otherwise recommended given the lack of quality evidence. In as 
much in such a setting it cannot otherwise be said 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 therapeutic apheresis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve therapeutic apheresis.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network psychologist referral. 
 
You asked the Plan to pre-approve the referral. You say that you would like to continue seeing this provider. 
The Plan denied your request. The Plan says the requested provider is not in the plan's 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 
an out-of-network psychologist referral.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 You asked the Plan to pre-approve the requested services. You say that the enrollee needs relief from pain he 
lives with every day. The Plan denied your request. The Plan says the enrollee has not tried and failed 4 weeks 
of conservative management. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic neck pain that radiates to her arm. She takes Tylenol and non-
steroidal anti-inflammatory drugs (NSAIDs) for the pain. The request is for a cervical epidural steroid 
injection. There is no documentation of conservative therapies that have been tried and failed. Therefore, at this 
time, the request is considered 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. 
The requested Superion spacer is considered experimental in nature, as more research is needed to show safety 
and efficacy. The services are therefore 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 a Vertiflex Superion spacer.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network orthopedic referral. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested provider is not in the plan's 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 
an out-of-network orthopedic referral.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Factor V Leiden (FVL) and Factor II (F2) Prothrombin 
genetic testing. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is only covered pregnant patients. 
 
The Plan must follow Medicare rules. Medicare rules say that FVL and F2 testing is only covered for pregnant 
patients. 
 
You do not qualify for this testing. 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 pre-approve Factor V 
Leiden (FVL) and Factor II (F2) Prothrombin genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement (11720) provided on July 7, 2021. 
  You asked the Plan to pay for nail debridement (11720). You say that the medical records should be reviewed, 
and the claim reconsidered for payment. The Plan denied your request. The Plan says an appropriate modifier 
was not billed with this code edit. 
 
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, we have confirmed that code 11720 
is a column II code to column I code 11719. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for nail debridement (11720) provided on July 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rytary capsules. 
 
You asked the Plan to pre-approve self-administered drug. You say that since starting this drug, the enrollee 
has had significantly improved mobility, gait, and balance without any side effects. The Plan denied your 
request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by 
Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug 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 Rytary capsules.  
 Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.