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

We decided that the Plan does not have to pay for x-ray examinations of the abdomen provided on August 10,
2021, by an out-of-network (OON) provider.
You asked the Plan to pay for x-ray examinations of the abdomen. You say that your company is not allowed
access to the patient demographics until the technologist is at the facility treating the patient, and your services
are treated as an emergency service in the nursing home and home health setting. You also say that these two
issues make getting a prior-authorization next to impossible. The Plan denied your request. The Plan says the
member received service from a non-contracted provider and the service was ordered by a provider who is also
a non-contracted provider. The Plan also says that there is no documentation to support that this provider
attempted to obtain an authorization prior to the provision 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 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 x-ray examinations of the abdomen provided on August 10, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a subcutaneous cardiac rhythm monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says that an implantable loop recorder are indicated when fainting (syncope) is thought to be 
cardiac-related but is too infrequent to be detected by an external heart monitor. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 monitor. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found you have a history of cryptogenic stroke. A 30 day ambulatory electrocardiogram was performed and 
was negative; however, atrial fibrillation is still suspected, hence the request for the ILR implant. Use of an ILR 
for this indication would be considered medically appropriate and reasonable in your clinical management.  
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 monitor have been met. Therefore, we decided that the Plan has to pre-
approve a subcutaneous cardiac rhythm monitor for the enrollee.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Logisticare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you must see your infectious disease 
doctor due to four back surgeries. You also say you must see a neurosurgeon. The Plan denied your request. 
The Plan says you are requesting additional miles and your benefit only allows 50 miles. The Plan also says 
you have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 36 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  We looked at your request, the records in the case file, and the rules. The records show that your request to 
travel to your provider in Macon, GA is an additional 2 miles for a total of 52 miles. The records also show that 
your request to your provider in Atlanta, GA is an additional 98 miles for a total of 148 miles. Based on this 
information, we decided that the Plans rules for coverage of routine transportation have not been met. 
Specifically, trips over 50 miles are not covered. Therefore, we decided that the Plan does not have to pre-
approve additional Logisticare mileage (A0170).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.
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 documentation does not support that you require at least 3 hours a day /5 days a week, or 15 hours over 7 consecutive days, of therapy services.
It is not clear 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement provided on June 7, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the debridement. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for debridement provided on June 7, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
22, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the hospital called the 
ambulance to transport the enrollee to a rehabilitation facility and you disagree with the charges. The Plan 
denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the 
correct 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $290 copayment for ambulance services.  
 
The enrollee has been asked to pay the allowed amount of $237.15, which is less than the $290 copayment for 
ambulance services. Ambulance services fall within the ambulance services benefit category. 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 ambulance services provided on October 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade for the enrollee. 
 
You asked the Plan to pre-approve Remicade. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the patient has not previously tried and failed or been intolerant to the preferred 
medications. 
 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 Remicade. Our reviewer says that 
Remicade is not medically reasonable and necessary. The enrollee has a diagnosis of sarcoid cardiomyopathy 
and has failed methotrexate. The requested medication is a new start. The provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternatives. 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 
alternatives. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for 
Remicade. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade for the enrollee.
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 these services are medically necessary. The Plan
denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The
complexity of your nursing, medical and rehabilitation needs do 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgical procedure performed on November 2, 2021.
You asked the Plan to waive the copayment for the outpatient surgical procedure. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for Outpatient hospital services.
You have been asked to pay a $325 copayment for an outpatient surgical procedure. 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 outpatient surgical procedure performed on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services of a perfusionist provided during a surgical 
procedure on August 13, 2021. 
 
You asked the Plan to pay for the perfusionist services. You say that these services were medically necessary 
and should be covered. The Plan denied your request. The Plan says no separate payment can be made for these 
services. 
 
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. The 
rules also indicate that in order to bill Medicare and receive payment, a provider must be enrolled in the 
Medicare program. 
 
Although these services may be appropriate, they are not considered physician services, and payment for them 
is made to the hospital which must then furnish these services either directly or under arrangements. As such, 
separate Medicare payment cannot be made for the services at issue. Therefore, we decided that the Plan does 
not have to pay for the services of a perfusionist provided during a surgical procedure on August 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for wound debridement services provided from 
September 2, 2021, to September 30, 2021. 
 
You asked the Plan to waive the deductible for the wound debridement services. You say that the services 
should be covered as you were not made aware of the copayment beforehand. The Plan denied your request. 
The Plan says the cost-sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $495 copayment for each Medicare-covered outpatient hospital 
facility visit, after you meet your $1,000 deductible. 
 
 
 
 
 
 The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies 
to outpatient surgery. This cost sharing is a contractual obligation that had not been met until the September 23, 
2021, claim. Therefore, $431.17 applied to the deductible for the services provided on September 16, 2021, and 
366.12 applied to the services provided on September 23, 2021 to meet the $1,000 deductible.  
 
Since the $1000 deductible was met, you have also been asked to pay a total of $1,594.18 for 4 wound 
debridement visits, which is less than the standard $495 copayment per visit. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that services were provided to the enrollee our of medical 
necessity and the claim should be paid. The Plan denied your request. The Plan says the rendering provider is 
an out-of-network provider with no 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 an office visit provided on September 1, 2021, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs received on October 31, 2021.
You asked the Plan to pay for the drugs. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
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 pay for self-administered drugs received on October 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on April 8, 2021.
You asked the Plan to pay for the drug testing. You say that this was coded correctly and should be paid. The Plan denied your request. The Plan says the reported POS code is not supported.
The Plan must follow Medicare rules. Medicare rules say that for 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. The documentation does not indicate this sample was taken by the
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not
have to pay for the drug testing provided on April 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pregabalin 150 mg tablet.
You asked the Plan to pre-approve Pregabalin. You say that this drug is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pregabalin 150 mg tablet.
Benefits for Pregabalin 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment
supported porcelain/ceramic crown (D6058) provided on September 27, 2021.
You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain/ceramic
crown. You say that that you feel that you should not have been charged for the implant supported abutment.
You also say that crowns are listed as a covered benefit which is what you agreed to pay extra for. The Plan
denied your request. The Plan says these services are not covered under your supplemental dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 pay for the custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on September 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OrthoVisc. 
 
You asked the Plan to pre-approve OrthoVisc. The Plan denied your request. The Plan says to meet coverage 
for this drug, aspiration must be tried first. 
 
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 OrthoVisc. Our reviewer says that the 
member does not meet the LCD coverage criteria and the requested procedure is not medically necessary or 
reasonable. Our physician reviewer found that the patient has not had any previous corticosteroid injections.  
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OrthoVisc have not been met. Therefore, we decided that the Plan does not 
have to pre-approve OrthoVisc.