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

 
We decided that the Plan has to pre-approve oral Ondansetron Hydrochloride tablet for the treatment of 
nausea/vomiting 
 
You asked the Plan to pre-approve oral Ondansetron Hydrochloride tablet. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says that the requested drug is not 
medically necessary. 
 
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 oral Ondansetron Hydrochloride tablet. 
Our reviewer says that the documentation does support that the requested drug is medically reasonable and 
necessary. Our physician reviewer found the enrollee has left lung cancer. The requested drug is FDA approved 
for moderate and higly emetogenic chemotherapy. Carboplatin meets this criteria. Therefore, the enrollee meets 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oral Ondansetron Hydrochloride tablet have been met. Therefore, we decided 
that the Plan has to pre-approve oral Ondansetron Hydrochloride tablet for the treatment of nausea/vomiting  
 
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: Favorable

 
We decided that the Plan has to pay for the lab services provided on September 3, 2019. 
 
You asked the Plan to pay for the services provided. You say that you were seen for a physical and were sent 
for lab work. The Plan denied your request. The Plan says that the services are not payable by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the services provided by a contract provider. The file does not show that the Plan 
provided notice that the services provided would not be covered. Under Medicare rules, this means the services 
are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services 
provided on September 3, 2019.  
 
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 waive the copayment for lab services you had on July 31, 2020, and 
September 1, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that these were routine lab services, 
not diagnostic, so no copayment should apply. The Plan denied your request. The Plan says these copayments 
were 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 $12 
copayment for laboratory tests.  
 
You have been asked to pay a $12 copayment for each of the lab services. These copayments apply regardless 
of the reason for the test. 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 lab services you had on 
July 31, 2020, and September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the core build up (D2950) provided on April 22, 
2020. 
 
You asked the Plan to reimburse you for the core build up. You say that you were advised that you could go to 
any dentist since the services were not cosmetic. You also say that you were advised that you would be 
reimbursed. The Plan denied your request. The Plan says core build up is not listed as a covered service. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for 
the core build up (D2950) provided on April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion consultation to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve a second opinion consultation to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria has not been met. 
 
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 
a second opinion consultation to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen. 
 
You asked the Plan to pre-approve Epogen. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Epogen. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found review of Medicare compendia support 
the use of the requested product to reduce the need for red blood cell transfusions in anemic patients scheduled 
for elective, non-cardiac, nonvascular surgery. Guidelines do not support the use for this beneficiary and 
medical necessity cannot be determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epogen.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 2, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that authorization should not be needed for payment 
of the services rendered. The Plan denied your request. The Plan says the services were not urgent, emergent, 
or approved in advance. 
 
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 services at issue in this appeal. 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 the medical services provided on July 2, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 services. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the records do not show that 
skilled nursing services are required to effectively provide treatment to maintain the enrollee's condition or 
prevent deterioration as she successfully performed and completed physical therapy in home with 
improvement, meeting goals met. Skilled therapy is not needed according to the records provided. Ongoing 
physical therapy can be successfully performed and continued without supervision to maintain strength and 
does not require skilled home 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77062) provided. 
 
You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT 77062 has a 
status indicator of I and is not valid for Medicare purposes. 
 
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 CPT code 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 77062 has a status indicator of I. This means CPT code 77062 is not valid for Medicare purposes. Based 
on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis 
have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic digital breast 
tomosynthesis (77062) provided.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0427, A0425) provided on 
November 8, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records only 
support one transport. 
 
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 codes A0427 and A0425 are not supported in the medical record. Specifically, the records 
provided support that one ambulance transport was provided on the date of service in question. The Plan has 
agreed to pay for one unit of A0427 and A0425. The additional units are not supported. 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 pay for the ambulance services (A0427, A0425) provided on November 
8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 27, 2020. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says you are limited to one diagnostic 
emergency exam every year. 
 
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. The Plan covers the limited 
oral evaluation. when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. You previously received a covered limited oral evaluation on July 28, 
2020 and exhausted the benefit for the 2020 calendar year. Based on this information, we decided that the 
Plan's rules for coverage of the limited oral evaluation have not been met. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation (D0140) provided on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS device. 
 
You asked the Plan to pre-approve the device. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no evidence that they have been enrolled in an approved category B 
investigational device exemption (IDE). 
 
The Plan must follow Medicare rules. CMS posts Medicare-covered Category A or B IDE studies on their 
website. Providers participating in and seeking Medicare reimbursement for items and services in Category A 
or B IDE studies, prior to submitting claims, are responsible for checking the CMS Coverage Website to 
identify whether CMS has approved the study for purposes of Medicare coverage. 
 
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 device. Our reviewer says that the 
 
 
requested CardioMEMS device is not medically necessary or reasonable. Our physician reviewer found there is 
no clinical rationale for the requested item. The provided documentation does not show that the member has 
been enrolled in an approved category B investigational device exemption (IDE) study such as NCT03387813 
Hemodynamic-GUIDEd Management of Heart Failure (GUIDE-HF). 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CardioMEMS device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and treatment (99213) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and treatment to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria has not been met. 
 
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 
an office visit and treatment (99213) 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 pre-approve an acute inpatient rehabilitation facility (IRF) admission and 
services. 
 
You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient 
rehabilitation facility admission. 
 
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 that you do 
not require the intensity of services provided at an inpatient rehabilitation facility. Specifically, you are not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. Your needs can be met 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 an 
acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories. 
 
You asked the Plan to pre-approve group 3 power wheelchair. You say that your wheelchair is not 2 years old 
and you want a wheelchair with a suspension. The Plan denied your request. The Plan says the denial of 
authorization for this device is correct, because you do not have a condition for which a group 3 power 
wheelchair would be medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair with accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this would provide significant clinical and 
quality of life benefits for their patient. The Plan denied your request. The Plan says that a review of the current 
medical literature indicates that this service is considered experimental and 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The spacer is 
experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found 
that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Superion interspinous spacer for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Surgery Vertiflex Superion Interspinous Device (CPT 
Codes 22869). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says medical studies haven't proven that the device(s) is helpful for treatment of the member's 
health problem. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is experimental. More research is needed to show safety and efficacy. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-
approve Surgery Vertiflex Superion Interspinous Device (CPT Codes 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0120) and prophylaxis (D1110) 
provided on August 4, 2020. 
 
You asked the Plan to pay for the dental services. You say that you have been very satisfied with the dentist in 
this case. You also say that you need him to be in network. The Plan denied your request. The Plan says the 
provider in this case is not a participating provider. The Plan also says that services are only covered when 
received by a participating provider. 
 
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, dental services that you receive out of 
network are not covered. Therefore, we decided that the Plan does not have to pay for the oral evaluation 
(D0120) and prophylaxis (D1110) provided on August 4, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for esophago-gastric duodenoscopy screening testing (43239) 
provided July 31, 2020. 
 
You asked the Plan to pay for the screening testing. You say that please review medical notes to show medical 
necessity of the claim. The Plan denied your request. The Plan says screening testing is not a Medicare benefit 
for the diagnosis as listed on the claim and are done for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the screening testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for esophago-gastric duodenoscopy screening testing (43239) provided July 31, 2020.