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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA to the SI joint. You say that this procedure is medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 RFA to the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found According to the literature, sacral lateral nerve branch blocks and/or 
ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational.  Radiofrequency ablation for denervation, whether performed using 
traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically 
necessary. The review has determined that the requested SI joint RFA is not medically reasonable or 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 RFA to the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The 
Plan denied your request. The Plan says that the requested Keytruda is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda. Our reviewer says that the 
requested Keytruda is medically necessary. Our physician reviewer found Medicare maintains a list of 
compendia which define if a use is medically accepted. The off-label use must be supported in one or more of 
these compendia or in published, peer-reviewed medical literature. An off-label use must be supported in one 
or more of the compendia and the use must not be listed as unsupported, not indicated, not recommended, or 
equivalent terms, in any of the compendia. An off-label use may also be determined by the carrier in the state 
to be reasonable and necessary. The National Comprehensive Cancer Network has stated as a 2A 
recommendation that the requested drug is indicated as adjuvant systemic therapy as a single agent for 
pathologically staged IIB/IIC sentinel node negative disease following wide excision.  
 
The record indicates that the enrollee has a diagnosis of stage IIC scalp melanoma. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved cancer drug compendia do contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation as noted above. The elements of the coverage criteria are satisfied. The requested 
service is 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (76856) provided on 
December 2, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered as 
you disagree with the charges. 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 $160 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 You have been asked to pay a $99.25 copayment for an ultrasound, which is less than the standard $160. 
Ultrasounds 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 an ultrasound (76856) provided on December 
2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on November 
18, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that the laboratory services are 
part of your annual wellness exam, so you should not have a copayment. The Plan denied your request. The 
Plan says copayment is 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 $0 copay 
for hemoglobin A1c, prothrombin (protime), and urine albumin and a $15 copayment for all other covered 
laboratory services with an in-network provider.  
 You have been asked to pay $15 copayment for laboratory services. Laboratory services fall within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. Laboratory services are 
considered a separate service. 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 laboratory services 
provided on November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit, routine venipuncture, and 
laboratory services provided on January 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital outpatient clinic visit, routine venipuncture, and laboratory services. 
You say that this facility regularly complies with all administrative requirements for payments. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan, and they have also 
determined that these services are not 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 hospital outpatient clinic visit, routine 
venipuncture, and laboratory services provided on January 20, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a year long supply of Privigen. 
 
You asked the Plan to pre-approve a year long supply of Privigen. You say that this drug is medically 
necessary. The Plan denied your request. The Plan says this medicine is not to be used as a long-term treatment 
for enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a year long supply of Privigen. Our 
reviewer says that Privigen to be given for a year is not medically reasonable and necessary. Our physician 
reviewer found the review has determined that the documentation does not support that Privigen to be given for 
a year is medically reasonable and necessary for the patient. The documentation does not support that Privgen 
to be given for a year is safe and effective for the patient. 
 
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 year long supply of Privigen have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a year long supply of Privigen.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing services provided on December 18, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory testing services. You say that the ordering physician requested the 
sample nodule(s) sent to this provider with an inter-determinate cytopathology result to undergo this service. 
The Plan denied your request. The Plan says the services were provided by a non-participating provider, the 
referring provider is also non-participating, and there is no valid authorization on file. 
 
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 laboratory testing services provided on December 
18, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Drug Testing provided on December 29, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Drug Testing. You say that you were unaware of the requirement to obtain prior 
authorization. The Plan denied your request. The Plan says the service obtained by the member was rendered 
by a provider who is not under contract. 
 
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 Drug Testing provided on December 29, 2021 by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (76700) provided on January 
13, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered as 
you disagree with the charges. 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 $170 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $130.07 copayment for an ultrasound, which is less than the standard $170. 
Ultrasounds 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 an ultrasound (76700) provided on January 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GenVisc 850. 
 
You asked the Plan to pre-approve GenVisc 850. You say that the requested GenVisc 850 is medically 
necessary. The Plan denied your request. The Plan says the enrollee must try and fail Euflexxa, Synvisc, or 
Synvisc-One 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 GenVisc 850. 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 records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. 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. 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 GenVisc 850 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve GenVisc 850.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says services 
can be provided at a lower level of care. 
 
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 continued services. Our physician 
reviewer found that clinical documentation shows continued need for skilled therapy and nursing services. 
Goals are stated, however, there is no frequency order or recommendation by care team. The enrollee continues 
to require physical assistance with lower body dressing, she is ambulating without an assistive device. For 
practical purposes, the enrollee does not require daily skilled therapy or nursing services in a skilled nursing 
facility on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozurdex. 
 
You asked the Plan to pre-approve Ozurdex. You say that this drug is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this drug is being requested for an off-
label use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Ozurdex. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the record indicates 
that the enrollee has a diagnosis of post-operative cystoid macular edema. The Food and Drug Administration 
has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug 
compendia does not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. The elements of the coverage criteria are not satisfied.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ozurdex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ozurdex.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. You say that the requested Synvisc-One is medically 
necessary. The Plan denied your request. The Plan says the enrollee must try and fail Euflexxa, Supartz FX, 
Durolane, or Gelsyn-3. 
 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 Synvisc-One. 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 records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a medical contraindication to or would have an adverse effect from the plan's 
preferred step one alternative. 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on June 15, 2021 
 
You asked the Plan to waive the copayment for a CT scan. You say that this bill should not be your 
responsibility as it is the providers fault they sent the bill late. The Plan denied your request. The Plan says you 
have been charged the correct copayment 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 $80 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as radiology center or medical clinic).  
  
You have been asked to pay a $80 copayment for the CT scan. The CT scan falls 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 CT scan provided on June 15, 2021.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.