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

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve a continuation of care with an OON provider. You say that you would like 
to continue care with the requested OON provider who is specialized in treating someone who does not have a 
stomach.  The Plan denied your request. The Plan says the requested provider is not in-network. The Plan says 
that there is not a compelling reason why the needed services could not be provided within the network.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continuation of care with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met.  Our physician 
reviewer found the records support that you are clinically stable and that you have in undergone prophylactic 
gastrectomy.  Appropriate expertise for your follow-up is locally available. Available records do not support 
outstanding medical conditions that cannot otherwise be adequately managed by in-network providers 
following contemporary evidence-based guidelines appropriate to your history and genetic risks. The medical 
necessity for OON services is not demonstrated by available documentation. 
 
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 continuation of care with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablets. 
 
You asked the Plan to pre-approve Ondansetron tablets. You say that the medication is medically necessary. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Ondansetron tablets. Benefits for Ondansetron tablets 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 2, 2022, to 
December 30, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 2, 2022. The NOA was not received by the Plan until January 
24, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from December 2, 2022, to December 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 30, 2022, to 
December 29, 2022. 
 You asked the Plan to pay for the home health services. You say that you originally submitted the NOA with 
different information.  You resubmitted with corrected information later. The Plan denied your request. The 
Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 30, 2022. The NOA was not received by the Plan until February 
16, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from November 30, 2022, to December 29, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, advanced life support and ground mileage provided 
on December 2, 2022. 
 
You asked the Plan to pay for the ambulance service, advanced life support and ground mileage. You say that 
the enrollee was transported from his home to the hospital and was not hospitalized at the time of transport. 
The Plan denied your request. The Plan says that the claim was processed correctly. 
 
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 was unable to obtain the medical records to address the discrepancy 
between the ambulance records and the previously billed inpatient care. Therefore, we decided that the Plan has 
to pay for ambulance service, advanced life support and ground mileage provided on December 2, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 12, 2022, 
to October 13, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says the medical criteria for an inpatient admission have not 
been met. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was relatively stable after mediation changes, and it was not expected 
that the patient would require hospital care that would likely cross two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided October 12, 2022, to October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 8, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an OON office visit. You say that this should be covered. The Plan denied your 
request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that uthorization rules 
apply for out-of-network physician and practitioner services, including office visits. 
 
We looked at the file and Medicare rules. The service at issue was not authorized. Based on this information, 
we decided that Medicare rules for coverage of an OON office visit have not been met. Therefore, we decided 
that the Plan does not have to pay for an office visit provided on February 8, 2023, by an out-of-network 
(OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that you are in pain. You say that you need the knee 
injections. You also say that it has been two months since your last injections. The Plan denied your request. 
The Plan says you have not tried and failed the preferred drugs, Synvisc or SynviscOne, or Orthovisc. 
 
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 Gelsyn-3. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that you have tried and failed the preferred drugs, Synvisc/Synvisc One or Orthovisc. The reviewer 
also found that there is no documentation provided indicating that the Plans required drugs would likely be 
less effective and/or likely have adverse effects for you. Therefore, the reviewer found that the step therapy 
criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3. have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy (45378). 
 
You asked the Plan to pre-approve a colonoscopy. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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 a colonoscopy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no personal nor family history of irritable bowel disease, of adenomas, of colon cancer, 
nor of polyposis syndromes. The 5-year recall interval under review does not meet the medically appropriate 
and necessary timeframe for surveillance of a diminutive hyperplastic polyp, nor do the enrollee's symptoms as 
described warrant the risks of colonoscopy as the next evaluative step.  
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 colonoscopy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a colonoscopy (45378).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 office visits to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the outpatient services. You say that you need a diagnostic second opinion. 
The Plan denied your request. The Plan says there are network providers that can provide these services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
3 office visits to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (code 99232) provided on December 
31, 2022. 
 
You asked the Plan to pay for the physician services. You say that the diagnosis code is payable. The Plan 
denied your request. The Plan says the diagnosis code F05 is not acceptable as a primary diagnosis. 
 The Plan must follow Medicare rules. Medicare rules say that for conditions that have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology, the etiology diagnosis code 
must be indicated before the manifestation diagnosis code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. The claim submitted indicates the manifestation 
diagnosis code (F05) is the primary diagnosis. However, coding guidelines require that the diagnosis code for 
the underlying condition must be coded first. Therefore, we decided that the Plan does not have to pay for the 
physician services (code 99232) provided on December 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 17, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tiering exception for Orthovisc (J7324). 
 
You asked the Plan to pre-approve a tiering exception for Orthovisc. You say that the exception is needed. The 
Plan denied your request. The Plan says the medication does not qualify for tier exceptions. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tiering exception for Orthovisc have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tiering exception for Orthovisc (J7324).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve venography, extremity, bilateral (75822), venography, 
extremity, unilateral (75820), venography, caval, inferior, with serialography (75825), selective catheter 
placement, venous system (36011, 36012), intravascular ultrasound (37252, 37253), ultrasound guidance for 
vascular access (76937), moderate sedation services (99152, 99153). 
   
You asked the Plan to pre-approve venography, extremity, bilateral, venography, extremity, unilateral, 
venography, caval, inferior, with serialography, selective catheter placement, venous system, intravascular 
ultrasound, ultrasound guidance for vascular access, moderate sedation services. You say that this is medically 
necessary. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 venography, extremity, bilateral, 
venography, extremity, unilateral, venography, caval, inferior, with serialography, selective catheter placement, 
venous system, intravascular ultrasound, ultrasound guidance for vascular access, moderate sedation services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the documentation does not support the medical necessity of 
venography and potential iliac venous intervention. There is no evidence of whole leg swelling and no 
documentation suggesting proximal venous disease on noninvasive imaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of venography, extremity, bilateral, venography, extremity, unilateral, venography, 
caval, inferior, with serialography, selective catheter placement, venous system, intravascular ultrasound, 
ultrasound guidance for vascular access, moderate sedation services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve venography, extremity, bilateral (75822), venography, extremity, 
unilateral (75820), venography, caval, inferior, with serialography (75825), selective catheter placement, 
venous system (36011, 36012), intravascular ultrasound (37252, 37253), ultrasound guidance for vascular 
access (76937), moderate sedation services (99152, 99153).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. 
There is no documentation of a trial and failure of conservative pharmacological therapy and simple analgesics. 
The records do not support that Durolane is reasonable and medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Durolane.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve the medication. You say that recent data suggests superior outcomes and 
better safety with Entyvio. The Plan denied your request. The Plan says that step therapy requirements 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 the medication. Our reviewer says that 
the criteria for coverage of Entyvio have not been met. Our physician reviewer found that the Plan requires a 
trial of Inflectra or Renflexis before they will approve Entyvio. The submitted records do not contain 
documentation of trial and failure of the requested drugs. The records also do not support that Inflectra or 
Renflexis would likely be less effective or have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Entyvio.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the requested device is necessary for 
the enrollee. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
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 a CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. Therefore, the reviewer 
found that the requested device 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Livalo. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee is intolerant to all other statins. 
You also say that this medication is their only option. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 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 Livalo.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.