Persius/hicric huggingface dataset:
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to reduce the cost sharing for an urgent care visit provided on October 11, 2021. 
 
You asked the Plan to reduce the cost sharing for an urgent care visit. You say that you were not advised by 
anyone that the doctor you were seeing was out of network. The Plan denied your request. The Plan says that 
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. Your 
contract with the Plan says that enrollees must pay 40% coinsurance for an out of network urgent care visit at 
an urgent care center. The contract also says that the annual deductible does not apply to urgent care center 
services.  
 
The Plan says your $750 deductible applies to an urgent care visit. Based on the Plan contract, however, you 
cannot be asked to pay more than 40% of the allowed amount for an out of network urgent care visit at an 
urgent care center ($107.53 allowed amount x 40% coinsurance = $43.01). According to the Plans contract 
urgently needed services at urgent care centers do not apply to the deductible. Therefore, we decided that the 
Plan has to reduce the cost sharing for an urgent care visit provided on October 11, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
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. The rules say that Medicare hylauronans are covered when specific 
criteria are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have knee 
osteoarthritis. You had a brief response to steroids and acetominophen but cannot use non-steroidal agents. You 
declined a physical therapy trial. The records do not show that you are unable to complete conservative non-
pharmacological therapy. The criteria for coverage of Euflexxa are not met and the services are not 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 Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
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 appears to be somewhat unstable and requires short-term additional acute 
care services that can be safely administered at the current facility until more stable. The enrollee does not 
require services at the LTACH that are not already available at the current facility. Transfer to LTACH is not 
medically necessary as it would not be clinically advantageous. Transfer may be considered when treatment 
has completed and the patient is more stable.  
 
 
 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 admission to a long term acute care hospital (LTACH)
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from October 
14, 2021, to November 12, 2021. 
 You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee does not require daily skilled services. 
 
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 the enrollee 
did not meet the Medicare criteria for SNF care. 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 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 from October 14, 2021, to November 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance services, advanced life 
support, emergency transport (A0427) provided on September 1, 2021 and September 6, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
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 $240 
copayment per date of service regardless of the number of trips for emergency ground ambulance services.   
 
 You have been asked to pay $480 ($240 copayment x 2) for the emergent ground ambulance services provided. 
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 copayments for the ambulance services, advanced life support, emergency 
transport (A0427) provided on September 1, 2021 and September 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. He 
has not tried and failed the Plan's required drugs, Orthovisc or Supartz FX. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Gelsyn-3 is 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 Gelsyn-3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing for 22 or more drug classes 
(G0483) provided September 30, 2021. 
 
You asked the Plan to pay for the drug screening. You say that due to the expansive clinical value of the testing 
you do that benefits the enrollee, you ask for reconsideration of the denial and request payment in full for the 
testing. The Plan denied your request. The Plan says the condition of the enrollee does not meet the Medicare 
rules for coverage. 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 pay for the drug screening. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the reviewed documentation indicates that the diagnosis is medication management of long 
term (current) drug therapy. The medical record sent by the provider shows a definitive UDT panel for multiple 
drug classes was performed but does not show screening test results which are positive or inconsistent with 
prescription medications, dosing schedules, or history and expected results. The review has determined that 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 drug screening have not been met. Therefore, we decided that the Plan does 
not have to pay for definitive urine drug testing for 22 or more drug classes (G0483) provided September 30, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 
81455 are denied as not medically necessary. 
 
We looked at the file and Medicare rules. The services are billed under code 81455. 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 pay for the laboratory services rendered on October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic, continuous glucose monitor supplies and 
accessories (K0553) rendered by the out-of-network (OON) provider on October 18, 2021. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items were rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. We 
found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does 
not have to pay for the therapeutic, continuous glucose monitor supplies and accessories (K0553) rendered by 
the out-of-network (OON) provider on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nerve conduction study provided on July 
20, 2021. 
 
You asked the Plan to waive the copayment for the nerve conduction study. 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 $10 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $10 copayment for a nerve conduction study. Nerve conduction studies fall 
within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a nerve conduction study provided on July 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on July 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 47120 is not supported. 
 
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, the CPT Code Manual definition of code 47120 is hepatectomy, resection of liver; partial 
lobectomy. 
 
We find that CPT code 47120 is not supported in the medical record. Specifically, there is no documentation of 
a hepatectomy with partial lobectomy. 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 pay for the surgical 
services rendered on July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 3 power wheelchair (PWC) coded as K0861 
with multiple power options including a power tilt/recline seating system. 
 
You asked the Plan to pre-approve the Group 3 PWC with multiple power options. You say that it is felt that all 
requested accessories are necessary for the enrollee's condition. The Plan denied your request. The Plan says 
the specific PWC base being requested is not covered per the Medicare criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options requires that the enrollee meet coverage criteria for a power tilt and recline seating system. The rules 
say that a power seating system  tilt only, recline only, or combination tilt and recline  with or without power elevating legrests will be covered if the enrollee is at high risk for development of a pressure ulcer and is 
unable to perform a functional weight shift; or, the enrollee utilizes intermittent catheterization for bladder 
management and is unable to independently transfer from the wheelchair to bed; or, the power seating system 
is needed to manage increased tone or spasticity. 
 
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 Group 3 PWC with multiple power 
options. Our reviewer says that the criteria for the requested wheelchair base are not met based on the records 
provided. Our physician reviewer found the enrollee is a male with a history of brain cancer with resulting left 
hemiplegia.  He meets criteria for use of a power mobility device; however, the documentation does not 
indicate that the member has any pressure injuries or requires intermittent catheterization of the bladder for 
which a power tilt/recline seating system would be required. As the requested PWC base cannot be covered 
unless the power tilt/recline system is also covered, the criteria for coverage have not been met. 
 
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 Group 3 PWC with multiple power options have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Group 3 power wheelchair (PWC) coded as K0861 
with multiple power options including a power tilt/recline seating system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is needed to treat bone loss caused from treatment 
of the enrollee's condition. The Plan denied your request. The Plan says the denial of authorization for this drug 
is correct, because a dual-energy X-Ray absorptiometry (DEXA) scan shows that the enrollee does not have 
osteoporosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Prolia. Our reviewer says that the 
enrollee does not meet the Medicare criteria for Prolia. Our physician reviewer found the enrollee has a 
diagnosis of breast cancer and is receiving an aromatase inhibitor. The enrollee has a normal bone 
densitomestry study. The Food & Drug Administration (FDA) has not stated that Prolia is approved for the 
enrollee's condition. The requested use is not supported by one of the major drug compendia or by clinical 
research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Prolia.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided from September 5, 2020, to 
September 8, 2020, at the original diagnosis related group (DRG). 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the medical record. The Plan denied your request. The Plan says that the 
diagnosis of sepsis, unspecified organism (A41.9) is not supported in the record, and therefore DRG 689 is 
more appropriate in this case. The Plan wants to recoup payment for these services as they are not supported as 
billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, none of the medical records reviewed by the Plan to approve 
medical necessity of these services and audit the submitted DRG were forwarded to us. We sent an additional 
request for these medical records, and they were not returned. Without the necessary medical records, we 
cannot verify the Plans findings. Therefore, we decided that the Plan has to pay for the inpatient hospital care 
provided from September 5, 2020, to September 8, 2020, at the original diagnosis related group (DRG).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the member has not 
tried and failed the preferred step therapy drugs Retacrit or Procrit. 
  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 Aranesp. Our reviewer says that the 
documentation does not support that the enrollee has tried and failed treatment with Retacrit or Procrit. Our 
physician reviewer found that the documentation does not support that Retacrit or Procrit would likely be less 
effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided from September 14, 2021, through 
September 30, 2021. 
 
You asked the Plan to pay for the chiropractic care. The Plan denied your request. The Plan says you already 
received 10 non spinal adjustments for 2021, and your benefit for chiropractic care has been exhausted. 
 
The Plan contract covers chiropractic care. The benefit covers up to 10 visits total for acupuncture and 
chiropractic visits combined per calendar year. 
 
We looked at the file and the Plans rules. The file shows that you already received 10 non spinal adjustments 
for 2021, and your benefit for chiropractic care has been exhausted. Therefore, we decided that the Plan does 
not have to pay for chiropractic care provided from September 14, 2021, through September 30, 2021.