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

 
We decided that the Plan has to pre-approve pegfilgrastim (Neulasta). 
 
You asked the Plan to pre-approve Neulasta. The Plan denied your request. The Plan says that the drug regimen 
of carboplatin and paclitaxel does not require prophylactic myeloid growth factors. 
 
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 Neulasta. Our physician reviewer found 
that the enrollee has stage IIIC ovarian cancer. The documentation shows that the Plan has approved 
Carboplatin, Paclitaxel, and Fosaprepitant. The requested use of Neulasta is FDA-approved to decrease the 
incidence of infection (as manifested by febrile neutropenia), in patients with non-myeloid malignancies 
receiving myelosuppressive cancer chemotherapy associated with a clinically significant incidence of febrile 
neutropenia. Carboplatin/Paclitaxel has an intermediate risk for neutropenic fever, but she received prior 
chemotherapy (6 cycles of same regimen) and has had recent surgery. Therefore, per the NCCN Guidelines, the 
enrollee meets criteria for coverage as these would increase her risk of neutropenic fever to greater than 20%. 
The documentation does support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have been met. Therefore, we decided that the Plan has to pre-approve 
pegfilgrastim (Neulasta).  
 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
February 12, 2020. 
 
You asked the Plan to pay for genetic tests. You say that the physician ordered this testing to determine if there 
was a more effective therapy to treat the enrollee's condition. The Plan denied your request. The Plan says the 
denial of payment for this testing is correct, because this testing was not billed with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing should be billed with CPT code 
81479 for date of service February 12, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic tests have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on February 12, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve ZILRETTA. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that 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 medically necessary. Our physician reviewer found the enrollee has a history of bilateral knee 
osteoarthritis. She had Orthovisc and Monovisc injections followed by ZILRETTA injection with good relief of 
symptoms for three months. ZILRETTA injections were done on November 5, 2019 and April 21, 2020 to 
bilateral knees which provided significant relief. The documentation supports that a repeat ZILRETTA 
injection is reasonable and medically necessary for the enrollee 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 been met. Therefore, we decided that the Plan has to pre-
approve ZILRETTA.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 13, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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. 
 
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 
services at issue. 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 laboratory services provided on April 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rotator cuff repair surgery. 
 
You asked the Plan to pre-approve rotator cuff repair surgery. You say that you would like the plan to 
reconsider their denial. 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 rotator cuff repair surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has shoulder pain. The documentation supports that surgery is 
not needed at this time. There are no red flags for surgery. The documentation does not support adequate 
documentation of conservative measures for shoulder pain. Therefore, the enrollee does not meet criteria for 
the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rotator cuff repair surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve rotator cuff repair surgery.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from September 27, 
2019 to September 30, 2019 by an OON provider. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services were authorized through 
September 26, 2019. You also say that the services were necessary for the enrollee's stay in your facility. The 
Plan denied your request. The Plan says these services were not authorized by the Plan prior to being 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 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 skilled nursing services provided from 
September 27, 2019 to September 30, 2019 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the bladder surgery provided on February 
20, 2020 to February 21, 2020. 
 
You asked the Plan to reduce the copayment for the bladder surgery. You say that you were told that inpatient 
services have a $295 copayment. You say you were admitted for over 25 hours and feel you are being 
overcharged. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $345 
copayment for surgery services at an in-network outpatient hospital. 
 
You have been asked to pay a $345 copayment for the bladder surgery. The bladder surgery falls within the 
Outpatient hospital services benefit category. The record shows that you were considered an outpatient. 
 
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 reduce the copayment for the bladder surgery provided on 
February 20, 2020 to February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injection. 
 
You asked the Plan to pre-approve facet joint injection. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered for certain 
indications. 
 
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 facet joint injection. Our reviewer says 
that the documentation does not support that the requested facet joint injection is medically reasonable or 
necessary. Our physician reviewer found this is a coding error. The enrollee has coccydynia not a facet 
arthropathy. This is NOT a facet joint injection; this should be a ganglion impar block. Therefore, the enrollee 
does not meet criteria for the requested facet joint injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve facet joint injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the benefit provides coverage for this drug when medically necessary. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary and does not meet step therapy coverage requirements. 
Our physician reviewer found the enrollee is noted to have osteoporosis as evidenced on a recent DEXA scan.  
The enrollee also has a remote history of hypocalcemia. There is no evidence that the enrollee has been taking 
supplemental calcium and vitamin D, or that these labs have been re-checked to assess efficacy. There is no 
evidence that the enrollee has tried and failed bisphosphonate medications.  There is no documentation as to 
why bisphosphonates would not be appropriate for or effective for this enrollee. As such, the documentation 
does not support that the request for Prolia is currently medically necessary or reasonable, or that step therapy 
criteria have 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
March 4, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the treating physician ordered this testing to 
determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing should be billed with CPT code 
81479 for date of service March 4, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on March 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient therapy provided by an out-of-network provider from February 4, 2020 through February 12, 2020.
You asked the Plan to pay for outpatient therapy. You say that you were not informed the provider was no longer in-network. You say that the claim should be overturned and paid. The Plan denied your request. The Plan says prior authorization was not requested for the enrollee to receive out-of-network 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 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 outpatient therapy provided by an out-of-network provider from February 4, 2020 through February 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the spinal neurostimulator electrode 
procedure provided on November 8, 2019. 
 
You asked the Plan to waive the copayment for the spinal procedure. You say that you were told that you 
would not have a copayment. You say you always pay a copayment for a surgical procedure, which this was 
not. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $255 
copayment for each covered surgery in an ambulatory surgical center.  
 
You have been asked to pay a $255 copayment for the spinal procedure. The spinal procedure falls within the 
Outpatient surgery, including services provided outpatient facilities and ambulatory surgical centers benefit 
category. The record shows this service is considered a surgical procedure. 
 
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 spinal neurostimulator electrode procedure provided on 
November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the lift chair provided on January 23, 
2020. 
 
You asked the Plan to waive the coinsurance for the lift chair. You say that you do not know why you received 
a check in the amount of $125.21 for the purchase of a lift chair. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment from an in-network durable medical equipment provider.  
 
You have been asked to pay $31.27 which is 20% of the allowed amount for the lift chair. The allowed amount 
is $156.33. ($156.33 x 20% = $31.27). The lift chair falls within the Durable medical equipment (DME) and 
related supplies benefit category. The record shows you were received $125.21 which is 80% reimbursement. 
 
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 for the lift chair provided by on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for arthroplasty (27130) provided on December 4, 2019. 
 
You asked the Plan to pay for the arthroplasty. You say that you would like reconsideration because the 
assistant at surgery was medically necessary. The Plan denied your request. The Plan says a registered nurse 
first assistant is not recognized for payment by CMS. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for arthroplasty (27130) provided on 
December 4, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 10, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan says comprehensive 
genomic profile testing, Guardant360, requires the use of CPT 81479. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the claim provided does not show that the coding and billing guidance has been followed.  
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant360 testing provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) 
rendered by the out of network (OON) provider on January 9, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network (OON) 
provider on January 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide visits and skilled nursing visits. 
 
You asked the Plan to pre-approve home health aide visits and skilled nursing visits. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health aide visits and skilled 
nursing visits. Our reviewer says that the documentation does not support that the requested home health 
services are medically reasonable or necessary. Our physician reviewer found you have had prior skilled 
nursing and were educated in disease management. There are no complex wounds, new enteral feedings or 
other skilled nursing need. The documentation does not support that skilled therapy is needed to effectively 
provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a 
maintenance program to maintain your level of function and/or prevent deterioration. You do not meet criteria 
for the requested services. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide visits and skilled nursing visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve home health aide visits and skilled nursing visits.