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

We decided that the Plan does not have to waive the cost share for the Euflexxa injections and specialist visits 
provided on July 22, 2020, July 28, 2020, and August 4, 2020. 
 
You asked the Plan to waive the cost share for the Euflexxa injections and specialist visits. You say that you 
feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your 
request. The Plan denied your request. The Plan says you received Euflexxa injections provided by a specialist 
on the dates of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your 
contract with the Plan. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs and a $50 copayment for specialist visits.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received Euflexxa 
injections on July 22, 2020, July 28, 2020, and August 4, 2020. You have been asked to pay a 20% coinsurance 
for the Euflexxa injections for each date of service, totaling $56.48 for the July 22, 2020 date of service, $56.48 
for the July 28, 2020 date of service, and $56.48 for the August 4, 2020 date of service. The Euflexxa injections 
fall within the Medicare Part B prescription drugs benefit category.  
 
The file shows you received each of these Euflexxa injections provided by a specialist; therefore, the specialist 
copayment of $50 also applied for each date of service. The specialist visits fall within the 
Physician/Practitioner services benefit category. This means that you have been asked to pay the correct 
amounts 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 cost share for the 
Euflexxa injections and specialist visits provided on July 22, 2020, July 28, 2020, and August 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PRALUENT 75mg/ml pen 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 Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 PRALUENT 75mg/ml pen 
for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for MRI scans of joints of the lower 
extremities (73721) performed. 
 
You asked the Plan to waive the copayments for MRI scans of joints of the lower extremities. You say that you 
have already paid what you were told to pay. The Plan denied your request. The Plan says the correct 
copayments were applied. 
 
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 $100 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays.  
 
The record shows that you received 2 MRI and 2 MRI scans as well. You have been 
asked to pay a $400 copayment, or a $100 copayment for each one of 4 MRI scans of joints of the lower 
extremities. MRI scans of joints of the lower extremities fall within the "Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies" 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 copayments for 
MRI scans of joints of the lower extremities (73721) performed.  
 
Your complaint about receiving erroneous or misleading information about your cost-sharing responsibility is 
not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided to the enrollee on June 16, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99232 is "subsequent hospital care." 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, this code was listed with a 
sequela code as the primary, first-listed, or principal code. This type of diagnosis code cannot be listed first. 
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 hospital services provided to the enrollee on June 
16, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve drug combination Bendeka, Polivy, and Truxima. 
 
You asked the Plan to pre-approve the requested drug combination. The Plan denied your request. The Plan 
says that the combination is not supported as a first line of treatment. 
 
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 the requested drug combination. Our 
physician reviewer found that this review is for the requested drug combination to treat recurrent diffuse large 
B cell lymphoma that recurred 5 years after the original diagnosis and treatment with chemotherapy. Truxima 
is Rituxmiab-abbs and per the NCCN compendium may be a substitute for Rituximab. The requested 
combination is not FDA approved. The NCCN Guidelines and the NCCN compendium both note the 
combination is recommended after at least 2 prior therapies. The Journal of Clinical Oncology cited a 
randomized study between Polatuzumab/Bendamustine/Rituximab (Pola-BR) and Bendamustine/Rituximab 
(BR). Of note is that this article is not cited in the NCCN guidelines noted above. Those guidelines cite a 2018 
abstract publication which was updated in the Journal of Clinical Oncology article. The use is not listed as not 
indicated, not recommended or not supported in any of the compendia. The regimen is safe and effective for 
the enrollee. In the opinion of this reviewer, the requested combination is medically reasonable and 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 the requested drug combination have been met. Therefore, we decided that the 
Plan has to pre-approve drug combination Bendeka, Polivy, and Truxima.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan (93975) provided. 
 
You asked the Plan to pay for a duplex scan. You say that this was billed correctly. The Plan denied your 
request. The Plan says the documentation supports a limited study rather than full. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93975 is duplex scan of arterial inflow and venous 
outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study. 
 
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 a duplex scan. Our reviewer says that this 
code is not supported. Our physician reviewer found the procedure report documents arterial inflow only, 
supporting a limited study.  To assign a complete study, there must be documentation of all major vessels 
supplying blood flow, both arterial inflow and venous outflow, for the organ evaluated. 
 
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 duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pay for a duplex scan (93975) provided.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional trips. You say that you need transportation to get to your 
appointments. The Plan denied your request. The Plan says your benefit only allows 60 trips for this service. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used 58 trips 
this year. Once you have used 60 trips, you will have exhausted the Plan maximum benefit for coverage of 
routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing exam provided on August 20, 
2020. 
 
You asked the Plan to waive the copayment for the hearing exam. You say that you didn't need the hearing 
evaluation. You say that you shouldn't be charged another copayment. The Plan denied your request. The Plan 
says the copayment applied 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 $20 
copayment in a physician?s office for routine hearing exams. 
 
You have been asked to pay a $20 copayment for the hearing exam. The hearing exam falls within the "Hearing 
services" benefit category. The hearing exam is considered a separate service. 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 hearing exam provided on August 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the care can be provided in the current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently undergoing treatment at an ACH for acute-on-chronic 
respiratory failure. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The 
enrollee has been weaned to a daytime tracheotomy collar. There are currently no documented plans for 
decannulation. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term 
care needs. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sedation for a lumbar injection. 
 
You asked the Plan to pre-approve the sedation. You say that this is medically necessary. The Plan denied your 
request. The Plan says the injection has been approved, but the sedation cannot be approved as well. 
 
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 sedation. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MAC service rendered must be appropriate and medically reasonable and necessary. In this 
case, there was no ASA score noted. MAC during SI joint injections is not considered the standard of care for 
the treatment of this enrollee's condition. There was no documentation provided necessitating the use of MAC. 
The review has determined that the medical records provided did not clearly establish a need for sedation 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 sedation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sedation for a lumbar injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the left knee for the enrollee. 
 
You asked the Plan to pre-approve the MRI. 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 MRIs are covered only when they are medically 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the recent physical 
exam of the extremities was unremarkable. There was no documented evidence of joint effusion or instability. 
No red flags. A six week trial of monitored PT has not been attempted. Absent conservative measures the 
medical necessity of MRI has not been established in the records submitted. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the left knee for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trifocal eyeglasses (V2020) and shipping costs provided. 
 
You asked the Plan to pay for trifocal eyeglasses and shipping costs. You say that you need specific eye glasses 
and are unaware of any provider?s in-network that can provide them. The Plan denied your request. The Plan 
says the items is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when purchased in-network. 
 
We looked at the file and the Plan's rules. You received your items from an out-of-network provider. Based on 
this information, we decided that the Plan's rules for coverage of trifocal eyeglasses and shipping costs have not 
been met. Therefore, we decided that the Plan does not have to pay for trifocal eyeglasses (V2020) and 
shipping costs provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested item. You say that the enrollee needs to know her sugar level 
before injecting insulin. The Plan denied your request. The Plan says the enrollee does not met the coverage 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation shows that you only use insulin twice a day. 
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 pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2752) for tooth # 19. 
 
You asked the Plan to pay for the dental service. You say that you need the crown to be replaced. You say that 
your dentist advised the tooth was going to decay and it needed to be replaced. You also say that you received a 
balance bill that the claim had been denied. The Plan denied your request. The Plan says there is no evidence of 
decay or missing crown to support the need for a replacement. 
 
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 dental 
service when the services are medically necessary and reasonable.  
 
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 the dental service. Our reviewer says that the 
crown for tooth # 19 is not medically necessary. Our physician reviewer found the documentation that was 
provided in this case was inadequate to determine the need for the replacement of the crown on tooth # 19. The 
reviewer found that there was no narrative explaining the need for a replacement. The reviewer also found that 
the radiograph provided was diagnostically inadequate. Therefore, the reviewer found that the requested crown 
for tooth # 19 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 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pay for the crown (D2752) for tooth # 19.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that all of the enrollee's attending physicians 
have determined that the enrollee is stable and that his ongoing medical needs warrant transfer to an LTACH. 
You say that the enrollee requires daily physician management with close medical monitoring and cannot be 
adequately care for in his current condition at a skilled nursing facility. The Plan denied your request. The Plan 
says the records show the enrollee has not completed the full course in the hospital. The Plan says that the 
enrollee is recovering from an acute illness and needs continued care, including medicine for infection through 
the vein. The Plan says that when the enrollee has finished care in the hospital, he can safely receive further 
care in another setting, such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the current acute care hospital with hypoxic respiratory 
failure related to pneumonia and lung abscess which was treated with drainage, antibiotics, and respiratory 
support. She was diagnosed with septic shock, which was monitored. Recent notes show the enrollee has 
improved overall with treatment but currently requires 1.5 L supplemental oxygen via nasal cannula. The 
enrollee appears to require additional short-term acute care services of less than 25 days which can be safely 
received in the current setting. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Therefore, this request for LTACH services will be 
considered not medically necessary at this time. Transfer to a lower level of care may be considered when the 
enrollee's treatment is completed. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.