Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $85.30 coinsurance for chemotherapy drugs administered 
on February 23, 2022. 
 
You asked the Plan to waive the $85.30 coinsurance for chemotherapy drugs administered on February 23, 
2022. You say that you should not be responsible to pay this coinsurance because the manufacturer will give 
you full assistance for this drug. The Plan denied your request. The Plan says you are responsible for a 20% 
coinsurance for chemotherapy drugs administered in an outpatient hospital setting. 
 
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 20% 
coinsurance for Medicare Part B Prescription Drugs. The Plan contract also states cost shares listed will apply 
to administrating of drugs in all places of treatment.  
You have been asked to pay an $85.30 coinsurance for chemotherapy drugs. Chemotherapy drugs fall within 
the Medicare Part B Prescription Drugs 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 $85.30 
coinsurance for chemotherapy drugs administered on February 23, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a SNF admission. You say that you need to continue taking treatment for 
your foot and you are not able to do that at home alone. You say that your doctor informed you that due to your 
inability you cannot be one your own at this time. The Plan denied your request. The Plan says the criteria for 
admission to a SNF have not been met. 
 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 a SNF admission. Our reviewer says 
that you do not qualify for SNF coverage. Our physician reviewer found you are on oral antibiotics and 
receiving intermittent wound care. You do not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of your condition. Your care needs can, as a 
practical matter, be provided at a lower level of care, such as assisted living facility or long term acute 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 a SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies 
received on October 22, 2021. 
 
You asked the Plan to pay for the CGM and supplies. You say that you need to stay on your current plan. The 
Plan denied your request. The Plan says you did not meet criteria for the items received. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor (CGM) and supplies received on October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service March 12, 
2021. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99233 is bundled into payment for code 99221. 
 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 99233 
is a column II code to column I code 99221. 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 procedure code 99233 billed for date of service March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle braces provided on February 22, 2022. 
 
You asked the Plan to pay for the ankle braces. You say that the patient meets Medicare criteria for these items. 
The Plan denied your request. The Plan says the medical records do not support the need for these items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is 
documentation in the patients medical record showing that that coverage criteria for the item have been met. If 
the information in the patients medical record does not adequately support the medical necessity for the item, 
the supplier is liable.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the medical records provided have zero references to ankle pain or instability, or any 
reference at all as to why ankle braces may have been ordered for this patient.  There is no evidence of any diagnoses affecting the patient's ankles in the medical records provided. Therefore, we decided that the Plan 
does not have to pay for ankle braces provided on February 22, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 18, 2020, 
through January 21, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient hospital care was 
medically necessary for the enrollee. The Plan denied your request. The Plan says that the inpatient hospital 
care provided was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record showed that at the time of the inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from January 18, 2020, through January 21, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99215) hemoglobin; glycated 
(83036) collection of capillary blood specimen (36416) provided on January 20, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are asking that this claim be reviewed for 
medical necessity based on the details below and the attached medical records. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
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. Also CPT code 36416 has a status of B for bundled code. Separate payment is never made 
for routinely bundled services and supplies. 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 office visit (99215) 
hemoglobin; glycated (83036) collection of capillary blood specimen (36416) provided on January 20, 2022 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on December 8, 2021. 
 You asked the Plan to pay for the services provided. You say that the claim denied as a duplicate in error. The 
Plan denied your request. The Plan says the service was bundled into another service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99232 was provided during a global surgery period. The code at issue was not billed 
with a modifier to indicate the service was unrelated to the surgery. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the subsequent hospital care provided on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive the $366.30 coinsurance for an Aflibercept injection on January 
25, 2022. 
 
You asked the Plan waive the $366.30 coinsurance for an Aflibercept injection on January 25, 2022. You say 
that the plan should cover the entire cost of this visit. The Plan denied your request. The Plan says you are 
responsible to pay a 20% coinsurance for all non-allergy antigens. 
 
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% 
coinsurance for out-of-network Medicare Part B Prescription Drugs. However, you have only been asked to 
pay $366.30, which is less than the 40% coinsurance amount. 
 
You have been asked to pay a $366.30 for an Aflibercept injection. An Aflibercept injection falls within the 
Medicare Part B Prescription Drugs benefit category. The provider billed $2120; the Plans allowance was 
$1831.50. $1831.50 x 20%= $366.30. 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 waive the $366.30 coinsurance for an Aflibercept injection 
on January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presumptive drug testing (80307) provided November 2, 
2021. 
 
You asked the Plan to pay for the drug testing. You say that this correspondence services as a 1st level provider 
administrative appeal/grievance regarding payments for services delivered. The Plan denied your request. The 
Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of presumptive drug testing (80307) 
provided November 2, 2021. have been met. The records show that the Plan made multiple attempts to obtain 
additional records from the provider without success. Therefore, we decided that the Plan does not have to pay 
for presumptive drug testing (80307) provided November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that the clinical information provided includes 
radiographic evidence of osteoarthritis. The appellant says that the enrollee has tried and failed conservative 
treatment, including over-the-counter medications and physical therapy. The Plan denied your request. The 
Plan says conservative treatments have not been tried for at least 3 months. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when the 
patient has failed at least three months of conservative therapy.  
 
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 Euflexxa. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found 3 months of conservative treatments for 
knee pain have not been completed. More conservative measures and time is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval. 
 
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 While the enrollee may benefit from evaluation and treatment by PT and OT, the enrollee's rehab needs can be safely provided in a lower intensity and alternate setting such as in an SNF based 
on her needs. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cancer panel provided on February 14, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the broad-
based panel is not indicated for rectal cancer. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The medical records do not clearly document that this testing was ordered 
as part of the enrollees treatment plan. The testing services were requested solely for screening purposes. 
Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have 
to pay for the hereditary cancer panel provided on February 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novolog. 
 
You asked the Plan to pre-approve Novolog. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered 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 Novolog.  
 
Benefits for Novolog 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has bilateral knee pain related to osteoarthritis in which the diagnosis was confirmed with 
imaging studies. The enrollee has failed conservative treatment. The documentation does not support that the 
enrollee has tried and failed Orthovisc or Supartz FX. The documentation does not support that Orthovisc or 
Supartz FX would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 21, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sent the specimen to 
your laboratory to process, and you would like the claim reprocessed for payment. The Plan denied your 
request. The Plan says the rendering and referring providers are both OON providers and there was 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 the laboratory services provided on October 21, 
2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that SNF admission is medically necessary 
after your surgery. The Plan denied your request. The Plan says they denied admission to the SNF based on the 
enrollee's current level of function and the enrollee not needing daily skilled therapy services. The enrollee's 
needs can be met at a lower level of care such as home health services or an assisted living facility. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that the requested SNF admission is not considered medically reasonable and necessary based on Medicare 
guidelines Our physician reviewer found that based on the documentation provided, it is my opinion that the 
enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The 
enrollee does not have documented skilled therapy needs. The enrollee is not shown to have an acute decline in 
function. Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of the enrollees 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the SNF admission.