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

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that you have tried and failed Alendronate, and your 
numbers have improved with Prolia. The Plan denied your request. The Plan says you do not meet the coverage 
rules, and this request is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Prolia have been met. Medical records 
were not provided for this case. The Plan made multiple attempts to obtain this information, but it was not 
received. Without medical records we cannot determine if the requested drug is medically necessary for your 
condition. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the home health aide services. You say that your hours were decreased to 2 
hours per week, from previously approved 4 hours/week, and that is not enough. You would like the hours to 
increase back to 3 hours and more if possible. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health aide services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found you 
do not have documented skilled nursing needs. You do not have documented skilled therapy needs. As such, 
home health aide services are not shown to be medically necessary or reasonable.  
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 home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22327 provided on July 14, 2022. 
 
You asked the Plan to pay for procedure code 22327. You say that the medical records support the billing of 
code 22327 provided on July 14, 2022. The Plan denied your request. The Plan says the medical records do not 
support the billing of code 22327 provided on July 14, 2022. 
 
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 22327 is Open treatment and/or reduction of vertebral 
fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; thoracic. 
 
We asked our coder 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 procedure code 22327. Our reviewer says that the medical 
records do not support the billing of code 22327 provided on July 14, 2022. Our reviewer found the operative 
report describes C2-L2 posterior spinal fusion with segmental instrumentation. Open treatment was performed 
at same anatomical area as the spinal fusion, and in this case would be the more comprehensive procedure, 
which is spinal fusion.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 22327 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 22327 provided on July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the federally qualified health center (fqhc) visit (G0466) 
provided on September 1, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient service. You say that the provider is in-network. The Plan denied 
your request. The Plan says prior authorization was not obtained. 
 
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 federally qualified health center (fqhc) visit 
(G0466) provided on September 1, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from an IRF stay after having 
your leg amputated. The Plan denied your request. The Plan says an IRF admission is not medically necessary, 
and the services you need can be provided safely in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you are medically stable and does not require close supervision for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. While you can benefit from 
physical and occupational therapy, your needs can be safely provided in an alternate level of care such as a 
skilled nursing facility. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 sensor kit. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 sensor kit. You say that the provided records support 
the necessity of the requested service. The Plan denied your request. The Plan says this enrollee does not meet 
the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre 2 sensor kit have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 2 sensor kit.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on 
September 26, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $250 
copayment for outpatient diagnostic tests/covered diagnostic procedure or test.  
 
You have been asked to pay a $250 copayment for outpatient diagnostic tests. This item/service falls within the 
outpatient diagnostic tests/covered diagnostic procedure or test 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 outpatient diagnostic tests provided on September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visits, and a 
laparoscopy provided from August 4, 2022, to August 30, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visits and a laparoscopy. You say that you 
did not receive these services. The Plan denied your request. The Plan says this cost sharing was charged 
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 $30 
copayment for services received from an in-network Level 1 specialist physician. Your contract with the Plan 
also clearly says that you must pay a $250 copayment for each visit to in-network an outpatient hospital 
facility.  
 
 The medical records show you received two specialist office visits on August 4, 2022, and had a laparoscopy 
on August 30 2022. You have been asked to pay $30 for the specialist office visits provided on August 4, 2022. 
These items/services fall within office visits benefit category. You have also been asked to pay $250 for a 
laparoscopy provided on August 30, 2022. This item/service falls within the outpatient surgery benefit 
category. The amount you owe is $310 ($30 + $30 + $250= $310). 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 specialist office visits, and a laparoscopy provided from August 4, 2022, to August 30, 2022.
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically
necessary.

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 do not
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee can receive further services at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on October 15, 2020, 
from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you used the OON provider because it had the 
hearing aids you needed. The Plan denied your request. The Plan says because the provider is OON with your 
plan and because you did not contact the Plan's hearing department to get in-network provider, the Plan will 
maintain its initial determination to not pay for the submitted claim. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when a Plan-approved hearing provider is used.  
 
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 hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5261) purchased on October 15, 2020, from an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the echocardiology (C8929) and drug requiring detailed coding 
(Q9957) provided on August 8, 2022. 
 
You asked the Plan to pay for the echocardiology and drug requiring detailed coding. You say that you would 
like this claim to be reprocessed for payment. The Plan denied your request. The Plan says that there is no 
documentation this enrollee was referred to this non-contracted provider by a contracted provider, as well as no 
indication any attempt was made to obtain prior authorization for the out-of-network services. 
 
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. The Plan did not provide a copy of the applicable 2022 Evidence of Coverage 
for this case. We asked for this document, but it was not provided to us. Without this information we cannot 
determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been 
adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their 
denial of payment in this case. Therefore, we decided that the Plan has to pay for the echocardiology (C8929) 
and drug requiring detailed coding (Q9957) provided on August 8, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate and Globus Kinex allograft for 
spinal surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate and Globus Kinex allograft. You say that this is 
medically necessary. The Plan denied your request. The Plan says these procedures are 
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 bone marrow aspirate and Globus 
Kinex allograft. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-
reviewed literature that shows bioactive allografts to be an effective and/or safe treatment for your condition. Further studies are needed to demonstrate that these services have beneficial outcomes compared to 
conventional treatments. There is no compelling rationale or extenuating circumstance noted to support the 
necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate and Globus Kinex allograft have not been met. Therefore, 
we decided that the Plan does not have to pre-approve bone marrow aspirate and Globus Kinex allograft for 
spinal surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis services, 4 or more physician visits per month, 
(90960) provided from July 1, 2022, to August 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dialysis services. You say that the office was not informed of the change in 
policy regarding prior authorization. You say that the enrollee has been on dialysis since 2018. You also say 
that this should be reconsidered. The Plan denied your request. The Plan says prior authorization was not 
obtained. 
 
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 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 dialysis services, 4 or more physician visits per month, 
(90960) provided from July 1, 2022, to August 1, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for light therapy treatments provided from July 
22, 2022, to September 6, 2022. 
 
You asked the Plan to waive the copayment for light therapy treatments. You say that you received these 
treatments before and were not charged a copayment. You do not understand why they are doing this now, as 
you are not seeing a specialist, just a tech. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $45 
copayment for Physician/Practitioner services, including doctor's office visits. You received 14 visits, with s 
$45 copayment for each, resulting in a $630 copayment (14 visits x $45 = $630). 
 
You have been asked to pay a compound $630 copayment for light therapy treatments. This item/service falls 
within the Physician/Practitioner services, including doctor's office visits 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 light therapy treatments provided from July 22, 
2022, to September 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
April 19, 2022, to April 23, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were unaware this 
new plan had worse copayments for inpatient stays, and want it removed. The Plan denied your request. The 
Plan says this cost sharing was charged 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 $275 
copayment per day, for days 1-5 and $0 after day 5 for inpatient hospital care. You were in the hospital for 4 
days, with a copayment of $275 per day, resulting in a $1110 total copayment ($275 x 4 days = $1110). 
 
You have been asked to pay a $1110 copayment for an inpatient hospital stay. This service falls within the 
inpatient hospital care 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 inpatient hospital stay provided from April 
19, 2022, to April 23, 2022.  
Your complaint about the Plan not outlining the copayments thoroughly 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.