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

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on April 8, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were not expecting this 
copayment and would like it reduced. The Plan denied your request. The Plan says the copayment applied was 
correct. 
 
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 $100 
copayment for diagnostic radiology services 
 
You have been asked to pay a $100 copayment for an ultrasound. An ultrasound falls within the Diagnostic 
Radiology Services, Such as Ultrasound, Nuclear Cardiac Imaging, PET, MRI, and CT Scan benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an ultrasound provided on April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alpha-Stim machine. 
 
You asked the Plan to pre-approve Alpha-Stim machine. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Alpha Stim device is only covered for certain 
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 Alpha-Stim machine. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has Bipolar Disorder. The enrollee has taken Seroquel and Effexor. 
This procedure is investigational for the treatment of Bipolar Disorder. Therefore, the enrollee does not meet 
criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Alpha-Stim machine have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Alpha-Stim machine.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 9, 2022, to February 9, 2022. 
 
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says a notice of 
admission document is required in order to process. 
 The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for the home health services have not been met. Specifically, . 
Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee 
from January 9, 2022, to February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis spine surgery (CPT code(s): 22633, 
63045). 
 
You asked the Plan to pre-approve the arthrodesis spine surgery. You say that the enrollee has tried and failed 
physical therapy (PT), has been diagnosed with worsening back pain. You state the enrollee has had a 
computed tomography (CT), magnetic resonance imaging (MRI) and x-ray. You state which showed 
spondylolisthesis spinal stenosis with nerve root compression and this is affecting the enrollee's daily life. You 
state the next step is surgical intervention, since all other modalities have been tried and failed. The Plan denied 
your request. The Plan says the services are not 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 arthrodesis spine surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures. Prior to undergoing an invasive 
surgical procedure, less invasive conservative measures are indicated. The examination does not corroborate 
any worsening neurological deficits to support the surgery without failure of the conservative measures. There 
are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. 
 
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 arthrodesis spine surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the arthrodesis spine surgery (CPT code(s): 22633, 63045).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on March 17, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-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 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 outpatient mental health services provided on 
March 17, 2022, by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro (CPT code J9144). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do not have a record from the enrollee's prescriber that shows the enrollee has 
tried the preferred drug Velcade and it hasn't worked, or that the enrollee has medical reasons that prevent them 
from using it. 
 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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Velcade or bortezomib before they will approve the requested drug. In 
this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided 
indicating that the plans required drug(s) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Darzalex Faspro (CPT code J9144).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Infliximab (CPT code J1745). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has not met the step therapy requirements. 
 
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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Avsola, Inflectra, and Renflexis before they will approve the requested 
drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided 
indicating that the plans required drug(s) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Infliximab (CPT code J1745).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination provided on March 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiologic examination. You say that the referring provider ordered the test. 
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 a radiologic examination provided on March 3, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantation of a left atrial appendage closure 
(LAAC) device (33340). 
 
You asked the Plan to pre-approve placement of a LAAC device. You say that the requested service is a 
medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for coverage of 
the requested service have not been met.  
The Plan must follow Medicare rules. The rules say that percutaneous LAAC is covered when the conditions 
listed in the Medicare rules section have been met. 
 
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 placement of a LAAC device. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you have no apparent contraindication to anticoagulation. As such, guidelines 
would not support implantation of a LAAC device in your clinical 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 placement of a LAAC device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantation of a LAAC device (33340).
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 for the enrollee. 
 
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 the enrollee can safely receive the services he needs 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. There 
is no evidence of complex needs beyond standard physical and occupational therapy assessment and 
intervention. The enrollee does not require frequent physiatry oversight or specialized rehabilitation therapies or techniques. The primary reason the providers state the enrollee needs an acute rehabilitation stay is for 
medical monitoring. The acute medical rehabilitation unit is for intensive rehabilitation needs or a complex 
interaction between medical and rehabilitation needs. The enrollee has neither. His medical condition does 
require monitoring but at an outpatient level and he does not have intensive rehabilitation needs. His post-acute 
rehabilitation needs are consistent with well-known and recognized condition commonly occurring in setting of 
chronic illness with acute exacerbation in older adults and handled without admission to an acute unit. Our 
physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laparoscopy (CPT code 44204). 
 
You asked the Plan to pre-approve the laparoscopy. You say that the enrollee has diverticulitis making the 
procedure medically necessary and the enrollee needs the surgery. The Plan denied your request. The Plan says 
the enrollee's records do not show confirmatory diagnosis of diverticulitis or treatment failure for diverticulitis. 
 
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 laparoscopy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found surgical consideration appears to be premature in the enrollee's case, especially without 
adequate and timely pre-operative evaluation having been provided in available records. 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 laparoscopy have not been met. Therefore, we decided that the Plan does not have to pre-
approve the laparoscopy (CPT code 44204).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on February 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-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 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 domiciliary services provided on February 22, 
2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physical therapy (PT) services provided on 
January 21, 2022, January 24, 2022, and January 26, 2022. 
 
You asked the Plan to waive the deductible for the PT services. You say that you were told eight sessions of PT 
would be covered without a charge. The Plan denied your request. The Plan says the deductible amount has 
been 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 says that there is a combined in-network and out-of-network medical deductible of $500 
which applies to PT services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Rehabilitation Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
a combined in-network and out-of-network medical deductible of $500 which applies to PT services. This cost 
sharing is a contractual obligation that had not been met at the time the PT services was received on January 
21, 2022, January 24, 2022, and January 26, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for physical therapy (PT) services provided on January 21, 2022, January 24, 2022, and January 
26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral device/appliance used to reduce upper airway 
collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment (E0486). 
 
You asked the Plan to pre-approve a custom fabricated mandibular advancement oral appliance. You say that 
you previously had 2 sleep apnea tests at home. You are having trouble falling asleep at night and sleeping a 
maximum of 3 hours per night. You need to sleep seated; your oxygen drops when you are asleep, and your 
teeth are falling apart because of the pressure you put on it at night. The Plan denied your request. The Plan 
says you do not meet the criteria for a custom fabricated mandibular advancement oral appliance based on your 
recent sleep study results which showed no evidence of obstructive sleep apnea. The Plan also says the 
requested item is non-covered because they are not primarily medical in nature. This means that they do not 
meet the definition of durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an oral device/appliance used to reduce upper airway 
collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment (E0486).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrocentesis, aspiration and/or injection, major joint or 
bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (CPT code 20610) and 
hyaluronan or derivative, orthovisc, for intra-articular injection (J7324). 
 You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because your records show you do not have 
documented trials of physical therapy or other exercise 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 the services. Our physician reviewer 
found detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures including medications and/or therapy. This is a noted 
contraindication as noted per the LCD. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, 
subacromial bursa); without ultrasound guidance (CPT code 20610) and hyaluronan or derivative, orthovisc, 
for intra-articular injection (J7324).