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

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you 
had at an orthopedic clinic on March 2, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that you don't think it is fair that the Plan 
paid nothing for this service. You think that the Plan should be obligated to pay a portion of the cost. The Plan 
denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the 
allowed amount for this service $143.83) is less than your copayment obligation, you are responsible for the 
full allowed amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $180 
copayment for advanced imaging services in a non-hospital setting.  
 You have been asked to pay a $180 copayment for the MRI. The MRI falls within the advanced imaging 
services in a non-hospital setting 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 
the magnetic resonance imaging (MRI) you had at an orthopedic clinic on March 2, 2021.  
 
Your complaint about how the Plan?s cost sharing is structured is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Glargine insulin pen. 
 
You asked the Plan to pre-approve Glargine. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Glargine insulin pen.  
 
 
 Benefits for Glargine 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the refraction (92015) provided on June 16, 2021.  You asked the Plan to pay for the refraction. You say that you would like reconsideration because you should only be liable for any amount above $75. The Plan denied your request. The Plan says the billed claim did not have any codes on it indicating that there was a routine vision exam.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when [Insert why/when the plan covers routine vision].  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Specifically, the refraction would be covered as part of a routine eye exam. The record does not indicate that a routine eye exam was rendered. Therefore, we decided that the Plan does not have to pay for the refraction (92015) provided on June 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve arthroplasty, glenohumeral joint; total shoulder (glenoid and 
proximal humeral replacement (eg, total shoulder)) (CPT code 23472), for the enrollee. 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the requested prosthetic repair of shoulder joint is not medically 
reasonable and necessary - shoulder dislocation is not a supported reason for shoulder replacement. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation demonstrates subjective and objective deficits that are 
corroborated by imaging studies. Trial and failure of conservative treatment modalities has been well 
documented and/or determined to not be indicated. There is a persistently painful, functionless right shoulder 
joint. In order to reestablish reasonable shoulder joint function and decrease persistent pain; medical literature 
supports the request. Therefore, the request for prosthetic repair of shoulder joint (right reverse total shoulder 
replacement CPT 23472) is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have been met. Therefore, we decided that the Plan has to pre-
approve arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total 
shoulder)) (CPT code 23472), 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapies (97162, 97110, 97112) provided on 
July 28, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient therapy. You say that these services were medically necessary. 
The Plan denied your request. The Plan says out-of-network care is generally not covered. There is no 
indication that these services were urgent or emergent, nor were they approved in advance. 
 
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 outpatient 
therapies (97162, 97110, 97112) provided on July 28, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81518) rendered by the out-of-
network (OON) provider on March 11, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (81518) rendered by the out-of-network (OON) provider on  
March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203) provided May 27, 2021. 
 
You asked the Plan to pay for the chiropractic service. You say that you feel that the Plan should pay for the 
services as you had called the day before and was told you had chiropractic benefits. The Plan denied your 
request. The Plan says this service is not covered by the Plan when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99203) provided May 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life 
support (ALS), emergency transport, level 1 (A0427) and ALS routine disposable supplies (A0398) provided 
June 25, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transport and ALS routine disposable supplies. 
You say that someone else decided that you should take an ambulance to the emergency room. The Plan denied 
your request. The Plan says the copayment has been applied correctly. 
 
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 $265 
copayment per date of service regardless of the number of trips by ground ambulance. 
  
You have been asked to pay a $265 copayment for the ambulance transport and ALS routine disposable 
supplies. The ambulance transport and ALS routine disposable supplies falls within the Ambulance services 
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 the ambulance service, advanced 
life support (ALS), emergency transport, level 1 (A0427) and ALS routine disposable supplies (A0398) 
provided June 25, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on May 14, 2021. 
 
You asked the Plan to pay for the testing services. You say that the treating physician makes the determination 
of medical necessity. The Plan denied your request. The Plan says the coding 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 G0483 is definitive drug testing for 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not 
show that the testing was ordered due to the enrollee?s history, medication side effects, or other clinician 
documented change in affect or behavioral pattern. Based on this information, we decided that Medicare rules 
for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay 
for the definitive drug testing provided on May 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current 
level of care. 
 
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 documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. 
 
 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve BIS, extracellular fluid analysis for lymphedema assessment(s) 
(CPT code 93702), for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the requested BIS is not medically reasonable and necessary - 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found all patients with breast cancer with surgery are at risk for lymphedema. BIS is used to assess 
lymphedema by measuring limb fluid content as an electric current passes through cell membranes and tissues. 
BIS is used for diagnosis as well as assessing treatment response. BIS is an increasingly utilized diagnostic 
technique that allows for the subclinical detection of lymphedema, prior to clinically evident disease. Early 
detection allows early treatment for prevention of clinically significant lymphedema. It has become a standard 
of care. The service is reasonable and 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve BIS, extracellular fluid analysis for lymphedema assessment(s) (CPT code 93702), 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that the requested Hyalgan is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first. 
 
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 Hyalgan. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of the knee.  The requested medication is a new start.  The provided record indicates 
that the enrollee tried and failed Orthovisc.  The provided records do not indicate that the enrollee has tried and 
failed the Plan's preferred step one alternative, Monovisc. 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 alternative, Monovisc.  
The elements of the coverage criteria are not satisfied.  The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Lucentis. 
 
You asked the Plan to pre-approve Lucentis. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of 
bevacizumab (Avastin) before it will approve Lucentis. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage for any item 
or service, the information submitted by the provider must corroborate the medical documentation and confirm 
that coverage criteria have been 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 looked at the file and Medicare rules. The Plan has implemented step therapy criteria requiring a trial of 
bevacizumab (such as Avastin) before it will approve Lucentis. You did not submit any medical records to 
support your request for Lucentis. The Plan made attempts to obtain medical records, but no records were 
submitted. Without medical records, we cannot determine whether the enrollee has tried and failed the Plan?s 
preferred drug of Avastin or if Avastin is contraindicated for the enrollee to support a step therapy exception 
for Lucentis. Therefore, you have not furnished sufficient information to support coverage of this request. 
Based on this information, we decided that Medicare rules for coverage of Lucentis have not been met. 
Therefore, we decided that the Plan does not have to pre-approve use of Lucentis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81194, 81210, 81235, 81275, 81276, 
81295, 81298, 81301, 81309, 81317, and 81401) provided on April 26, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent 
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we 
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services (81194, 81210, 81235, 81275, 81276, 81295, 81298, 
81301, 81309, 81317, and 81401) provided on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed with side rails. 
 
You asked the Plan to pre-approve the hospital bed. You say that your doctor had gave you a prescription for a 
hospital bed and you have been paying for this bed the entire year and is just now being told this was denied. 
The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria for 
the requested semi-electric hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 hospital bed. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is documentation that the enrollee's condition may require position of the body in ways 
not feasible in an ordinary bed, requires frequent changes in body position or immediate changes in body 
position and that the enrollee's condition requires special attachments that cannot be fixed and used on an 
ordinary bed. Based on the medical records provided there is no documentation that the enrollee meets 
Medicare criteria for medical necessity for the semi-electric hospital bed. 
 
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 hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a semi-electric hospital bed with side rails.