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

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
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 
Keytruda is not medically reasonable and necessary for the enrollee in this case. Keytruda is not FDA-approved 
for the enrollees diagnosis. Keytruda is FDA approved for the treatment of recurrent locally advanced or 
metastatic squamous cell carcinoma of the esophagus in patients whose tumors express PD-L1 (CPS =10) as 
determined by an approved test, with disease progression after one or more prior lines of systemic therapy. 
FDA approval is similar for head and neck cancer. No PD-L1 testing is provided. The use of Keytruda for the 
enrollee's diagnosis is not supported by one of the major drug compendia or by clinical research that appears in 
a CMS-approved medical journal. The use of Keytruda for the enrollee's diagnosis is not listed as not indicated, 
not supported or not recommended in any of the compendia. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of Keytruda. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 23, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on January 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA 1 and 2 testing for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no reason to re-test for BRCA 1 and 2 mutations when it is known that the 
enrollee does not have a mutation. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found cholangiocarcinoma with ATM mutation does not meet LCD requirements for BRCA1/2 testing. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve BRCA 1 and 2 testing for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Flovent HFA. 
 
You asked the Plan to pre-approve the Flovent HFA. You say that you would like reconsideration because the 
member needs this inhaler due to their condition. The Plan denied your request. The Plan says this inhaler is 
not covered under Medicare Part B for the member's condition. 
 
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 Flovent HFA.  
 
Benefits for the Flovent HFA 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: 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 need to adjust to your prosthetic leg. The Plan 
denied your request. The Plan says your care is not complex, and does not need a team of providers. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for a lower extremity infection and high blood sugar. You have 
been discharged to home care. Your medical problems are stable. The complexity of your nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The medical record supports a need for physical and occupational therapy, but it does not 
support a need for an intensive rehabilitation therapy program. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay you had from 
June 21, 2020, to July 14, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were never told 
there would be a copayment for this service. The Plan denied your request. The Plan says you were charged 
this copayment 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 $0 
copayment for days 1 and 2, a $125 copayment per day for days 3 through 7, and $0 per day for days 8+ for 
inpatient hospital care.  
 
Records show you were an inpatient for 23 days.  You were not charged a copayment for days 1 and 2.  You 
were charged a $125 copayment per day for days 3-7, for a total of $625. You were not charged a copayment 
for the remaining days of your inpatient stay. 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 inpatient 
hospital stay you had from June 21, 2020, to July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe LifeVest you rented from February 13, 2020, to July 13, 2020.You asked the Plan to waive the coinsurance forthe LifeVest. You say that you were never told there was a cost associated with this item.  You were under the impression that this item was approved by your plan.The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the LifeVest. The LifeVest falls within the durable medical equipment 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 coinsurance forthe LifeVest you rented from February 13, 2020, to July 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (CPT Code 64624). 
 
You asked the Plan to pre-approve the services. You say that you are currently in pain and are unable to bend 
your knee which makes it difficult to complete your physical therapy sessions. The Plan denied your request. 
The Plan says the services are considered experimental, investigational, or unproven for treatment of any of the 
following conditions such as knee pain. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is an experimental/ investigational procedure that is the subject of on-going clinical trials. 
Therefore, it is considered not 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, 
when performed (CPT Code 64624).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health services provided. 
 
You asked the Plan to waive the copayment for the outpatient mental health services. You say that you had a 
verbal agreement with the staff at this provider to not pay copayments. The Plan denied 
your request. The Plan says you were appropriately charged these copayments in accordance with your 
contract. 
 
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 per visit for outpatient mental health care.  
 
You have been asked to pay a $30 copayment per visit for the outpatient mental health servicesThis 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 mental health services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation, prophylaxis, and 
bitewings provided on July 2, 2020 by an OON provider. 
 
You asked the Plan to pay more for the comprehensive oral evaluation, prophylaxis, and bitewings. You say 
that the provider's office told you that the services would be covered in full. The Plan denied your request. The 
Plan says these services were paid by the Plan at the allowed amounts. The Plan also says that you signed a 
financial policy form from the dentist acknowledging that you were aware of the practice billing policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference 
between the billed amount and allowed amount. The record shows that the Plan confirmed with the provider's 
office that you were advised this provider is OON with the Plan. Therefore, we decided that the Plan does not 
have to pay more for the comprehensive oral evaluation, prophylaxis, and bitewings provided on July 2, 2020 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the podiatry visits you had on June 3, 
2020, and June 8, 2020. 
 
You asked the Plan to waive the copayments for the podiatry visits. You say that you shouldn't have to pay 
these copayments because the doctor didn't treat your problem. The Plan denied your request. The Plan says 
you were charged these copayments 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 $50 
copayment for podiatry visits.  
 
You have been asked to pay a $50 copayment for the podiatry visits. These copayments apply regardless of 
your satisfaction with the services. 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 copayments for the podiatry visits 
you had on June 3, 2020, and June 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveprosthetic adjustments to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethese OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network provider.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-approveprosthetic adjustments to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray provided on July 16, 2020. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you did not know what kind of x-ray the 
provider took. You also say that the provider should have contacted the Plan to see if this x-ray would be 
covered. The Plan denied your request. The Plan says the benefits for this service are limited to one time per 
thirty-six month period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, panoramic x-rays are limited to 1 per 
36 months. The record shows that you received a panoramic x-ray on February 26, 2019, and your panoramic 
x-ray benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-
ray provided on July 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this reprocessed and paid. 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 has network providers 
available who can provide 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 physician services provided 
by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional physical therapy visits. 
 
You asked the Plan to pre-approve 14 additional physical therapy visits. You say that she has continued right 
leg weakness which results in impaired gait, functional mobility and lack of endurance. You say that these 
require necessary physical therapy. The Plan denied your request. The Plan says additional visits are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 14 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had extensive therapy 
for this condition and does not require the unique skills of a professional therapist to safely and effectively 
provide ongoing treatment. 
 
 
  
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 14 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 14 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive orthodontic treatment of the adult dentition (D8090) provided on May 18, 2020.You asked the Plan to pay forthe dental service. You say that you were advised that you needed to align your teeth to prevent further deterioration. You say that the Invisalign is not for a "pretty smile". You say that this is to improve the health of your teeth and overall working of a betterbite.The Plan denied your request. The Plan says the orthodontic treatment is not listed as a covered service. The Plan also says services not listed above are not covered and the responsibility of the member.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the orthodontic treatment is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forcomprehensive orthodontic treatment of the adult dentition (D8090) provided on May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional diabetic supplies (A4253, A4259). 
 
You asked the Plan to pre-approve additional diabetic supplies. You say that the additional test strips and 
lancets are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that for a beneficiary who is not currently being 
treated with insulin injections, more than 100 test strips and more than 100 lancets every 3 months are covered.  
 
We looked at the file and Medicare rules. The record does not show any medical reason why the enrollee must 
test more than once daily. Based on this information, we decided that Medicare rules for coverage of additional 
diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional diabetic supplies (A4253, A4259).
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical 
records provided you do not require an intensive inpatient rehabilitation therapy program. There is no 
documentation that you require the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on May 28, 2020. 
 
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 procedure code 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 32550. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 32550. Code 71045 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on May 28, 2020.