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

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on December 
17, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the services should be 
covered as you have never had a charge like this before. 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, specifically laboratory 
services.  
 
You have been asked to pay a $10 copayment for laboratory services. Laboratory services 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 laboratory services provided on December 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on July 11, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you did not want to go to the hospital due to 
the coronavirus and the restrictions. You also say that you feel you should not be responsible for this bill. The 
Plan denied your request. The Plan says since there was no transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 11, 2021. The ambulance benefit is a 
transportation benefit.  
 
 
 
 When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided 
that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on 
July 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint (64625). 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that the services are medically 
necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered. 
 
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 radiofrequency ablation. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found radiofrequency ablation of the sacroiliac joint is considered investigational 
because of the wide variation in efficacy reported in the peer reviewed literature. 
 
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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint (64625).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection services. 
 
You asked the Plan to pre-approve epidural steroid injection services. You say that these services are medically 
reasonable and necessary for your condition. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that patients should be part of an active rehabilitation 
program, home exercise program or functional restoration program for epidural steroid injections to be 
covered. 
 
We looked at the file and Medicare rules. In this case, the medical records do not clearly show that you are 
currently involved in an active rehabilitation program, home exercise program or functional restoration 
program. Based on this information, we decided that Medicare rules for coverage of epidural steroid injection 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural steroid 
injection services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 25, 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 enrollee was on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory services rendered on August 25, 2021.
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 
16, 2021, to November 14, 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 that 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. Specifically, the file does not show that the 
enrollee required daily skilled services. Therefore, we decided that the Plan does not have to pay for the skilled 
nursing facility (SNF) care provided from October 16, 2021, to November 14, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ziextenzo. 
 
You asked the Plan to pre-approve Ziextenzo. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says step therapy criteria have not 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 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 Ziextenzo. Our reviewer says that this 
drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of two of 
the preferred step therapy drug, Neulasta (pegfilgrastim), Fulphila (pegfilgrastim-jmdb) and Udenyca 
(pegfilgrastim-cbqv), before coverage can be approved. Based on the medical records provided the patient has 
not tried and failed the required drugs. In this case, there is no indication that the plan's required drug(s) would 
likely be less effective and/or likely have adverse effects 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 Ziextenzo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ziextenzo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits (99204, 99213), and a biopsy of the 
vulva/perineum (56605) provided from December 3, 2020, to March 11, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for office visits and a biopsy of the vulva/perineum. You say that when you called 
the provider for an appointment, you asked if they took your Plan and they said yes, and then was informed the 
reading of the biopsy might not be covered. You also say that if you had known the services might not be 
covered, you would have gone to someone else. The Plan denied your request. The Plan says the provider who 
wrote the referral was no in in-network provider at the time the referral was written, nor did the Plan approve 
the referral and/or preauthorization. The Plan also says that there were in-network providers that were available 
that could have provided the services rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 office visits (99204, 99213), and a biopsy of the 
vulva/perineum (56605) provided from December 3, 2020, to March 11, 2021, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services (86891, 99190, 99191, P9022) provided on 
October 18, 2021. 
 
You asked the Plan to pay for inpatient services. You say that you have provided medical records to support the 
medically necessary services at issue. The Plan denied your request. The Plan says rules for payment have not 
been met because the charges for the services at issue are included in the facility payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for inpatient hospital services 
under the PPS. All items and non-physician services furnished to inpatients must be furnished directly by the 
hospital or billed through the hospital under arrangements. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of inpatient services have not been met. Specifically, the record indicates that the enrollee was registered inpatient on the billed date of service. Payment for the services at issue is included in the payment to 
the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not 
have to pay for inpatient services (86891, 99190, 99191, P9022) provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 16, 2021. 
 You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on February 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post stabilization care from 1:58pm on July 30, 2021, to 
1:14pm on July 31, 2021. 
 
You asked the Plan to pay for the post stabilization care. You say that the claim has been underpaid. The Plan 
denied your request. The Plan says the enrollee's emergency medical condition stabilized by 1:57pm on July 
30, 2021, and subsequent care was post stabilization care, not approved in compliance with the health plan's 
authorization procedures. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization care. Our reviewer says 
that the post stabilization care was not medically necessary. Our physician reviewer found that the review 
indicates that all care provided after 1:57pm on July 30, 2021, through 1:14pm on July 31, 2021, was not 
needed on an emergent basis. After 1:57pm on July 30, 2021, the enrollee was hemodynamically stable and 
appropriate for ambulance transfer with monitoring to a Plan facility. The post stabilization care services from 
1:58pm on July 30, 2021, to 1:14pm on July 31, 2021, at the non-Plan facility were not medically necessary 
and reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that 
the enrollee was not stable for transfer on any dates of service. 
 
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 post-stabilization care have not been met. Therefore, we decided that the 
Plan does not have to pay for the post stabilization care from 1:58pm on July 30, 2021, to 1:14pm on July 31, 
2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF 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 you 
meet the Medicare criteria for SNF care. Our physician reviewer found based on the medical records provided 
there is documentation that daily skilled therapy services are required. Your debility and increased oxygen 
requirements after your acute illness are a decline in function that is consistent with the description of a setting 
in which daily skilled therapy services are warranted, as described in the Medicare guidelines. Based on the 
medical records provided there is documentation that you require the services on an inpatient basis in a skilled 
nursing facility 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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One injections (J7325). 
 
You asked the Plan to pre-approve the Synvisc-One injections. You say that the injections are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the Synvisc-One injections. Our 
reviewer says that the injections are not medically necessary. Our physician reviewer found a trial of physical 
therapy is appropriate before viscosupplementation. The record shows no trial of therapy. 
 
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 Synvisc-One injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Synvisc-One injections (J7325).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria 
 
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 the documentation does not reveal evidence of 
complex wound care, new enteral feedings, or other skilled nursing SNF needs. Your functional level does not 
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require 
skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical 
matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility 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 cre have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on 
November 10, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that since the member was in a nursing 
facility, the doctor was not responsible to get authorization. You also say the nursing home was responsible to 
obtain prior authorization for their patients. The Plan denied your request. The Plan says an authorization was 
not obtained prior to the services being rendered, and the provider is not participating with the Plan. The Plan 
also says that it was determined the services were not urgent or emergent in nature. 
 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 domiciliary or rest home visit (99336) provided 
on November 10, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve BRCA1 and BRCA2 genetic testing. 
 
You asked the Plan to pre-approve BRCA1 and BRCA2 genetic testing. You say that  The Plan denied your 
request. The Plan says that Medicare guidelines for coverage have not been met. The Plan says that the 
enrollee's records show malignant neoplasm of the breast. the Plan says that the enrollee has cancer in her right 
breast and previously had cancer in her left breast treated with a lumpectomy and radiation in 2008. The Plan 
says that the enrollee has no family history of cancer. 
 
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, the Plan did not provide us with any medical records. In addition, 
the Plan references medical records in the reasoning for their determination. We attempted to obtain this 
necessary information from the Plan but did not receive a response. Without this information, the Plan has not 
substantiated their denial reason. Therefore, we decided that the Plan has to pre-approve BRCA1 and BRCA2 
genetic testing.  
 
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.