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

We decided that the Plan does not have to pay for the TDAP vaccine provided on April 16, 2020. 
 
You asked the Plan to pay for the TDAP vaccine. You say that you cannot afford to pay this charge. The Plan 
denied your request. The Plan says this claim was not billed with a diagnosis related to an injury or direct 
exposure to a disease or condition. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine. 
Therefore, we decided that the Plan does not have to pay for the TDAP vaccine provided on April 16, 2020.  
 
Benefits for the TDAP vaccine 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this device is proven to help better 
manage heart failure and should be covered. The Plan denied your request. The Plan says there is not sufficient 
evidence that this is an effective treatment. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found therapy change based on data obtained from a CardioMEMs device has been 
demonstrated in only one trial to help reduce hospital readmission compared to standard medical 
therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met 
since the device should still be considered experimental or investigational. 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of a CardioMEMS device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enstilar Aer topical foam. 
 
You asked the Plan to pre-approve Enstilar Aer topical foam. You say that the member has diagnosis of 
psoriasis and has tried and failed topical steroids in the past, but the member is responding well to this 
treatment. The Plan denied your request. The Plan says covered drugs include drugs that usually are not self-
administered by the patient and are injected or infused while the member is getting physician, hospital 
outpatient, or ambulatory surgical center services. Enstilar falls under Part D coverage, but the members Plan 
does not have a Part D pharmacy benefit. 
 
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 Enstilar Aer topical foam.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on December 30, 2019. 
 
You asked the Plan to pay for genetic tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the 
documentation submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken 
in an office setting, therefore the Place of Service (POS) code 81 ? indicating an independent laboratory setting 
? is not appropriate for this claim. 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 genetic testing 
provided on December 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a skilled nursing facility does not have 
the capability to administer the medication the enrollee needs. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare guidelines for care in a LTACH. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. Our reviewer found that there are no services available at the 
LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. Our physician reviewer also found that the requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(C-PAP) machine you rented from July 20, 2020, to August 20, 2020. 
 
You asked the Plan to waive the coinsurance for the C-PAP machine. You say that this amount has increased 
and you were not advised that the amount would go up. The Plan denied your request. The Plan says you were 
charged this coinsurance correctly.  The Plan says that the Medicare-allowed rate changed and your 
coinsurance properly reflects that. 
 
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 and related supplies.  
 
You have been asked to pay 20% coinsurance for the C-PAP machine. The C-PAP machine falls within the 
durable medical equipment and related supplies benefit category. Medicare updates its rates for durable 
medical equipment on a quarterly basis, so the amount may change throughout the year. 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 continuous positive airway pressure (C-PAP) machine you 
rented from July 20, 2020, to August 20, 2020.
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. The Plan denied your request. The Plan says you do not need to 
take part in 3 hours of therapy a day. 
 
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 are at a total assist level for bed rolling, moderate assist for sitting up and standing up, maximal assist 
for walking, and moderate assist for sitting down. You do not require the intensity of services provided at an 
IRF.  Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMs. 
 
You asked the Plan to pre-approve CardioMEMs. 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 CardioMEMs. 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 a history of atrial fibrillation, cardiomyopathy now improved, AVNRT and 
NYHA class III congestive heart failure with preserved ejection fraction (LVEF 54%) requiring hospital 
admission. In this circumstance therapy change based on data obtained from a CardioMEMs device has been 
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. 
Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure. 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 CardioMEMs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMs.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received at an outpatient 
hospital facility on June 9, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that you were not told that if you used 
the lab at the hospital there would be a copayment.  You said that you are on a fixed income. 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 $10 
copayment for lab services at an outpatient hospital facility.  
 
You have been asked to pay a $10 copayment for the lab 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 
copayment for lab services you received at an outpatient hospital facility on June 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health aide services received from April 15, 2020, to 
May 22, 2020. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is custodial care. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in 
this appeal. Therefore, we decided that the Plan does not have to pay for home health aide services received 
from April 15, 2020, to May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ophthalmology exam and the scanning 
computerized ophthalmic diagnostic imaging (SCODI test) you had on March 29, 2020. 
 
You asked the Plan to waive the copayments for the ophthalmology exam and SCODI test. You say that you 
should only have to pay your specialist copayment for this service. The Plan denied your request. The Plan says 
you were charged these two copayments appropriately.  The Plan says that because the allowed amount for the 
SCODI test is less than your copayment obligation, you are responsible for the full 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 $50 
copayment for diagnostic procedures and tests and a $40 copayment for specialist visits.  
 
You have been asked to pay a $40 copayment for the ophthalmology exam and a $50 copayment for the 
SCODI test. Plans are permitted to charge multiple copayments if multiple services are received, which was the 
case here. 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 ophthalmology exam and the scanning 
computerized ophthalmic diagnostic imaging (SCODI test) you had on March 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan 550 MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says this medication is not covered. 
 
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 Xifaxan 550 MG tablet.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 
80159, and 80173 provided on February 20, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, the documentation submitted does not support that the services were provided by blood 
specimen. Blood specimen collection is by venipuncture, however, the lab requisition states a urine specimen 
was collected; therefore, the billed services cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 80159, and 80173 
provided on February 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
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 you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says lymphedema extending to the chest and trunk is minimal. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
 
 
found based on the medical records provided there is no documentation that the enrollee has unique 
characteristics that would indicate the segmented pump over a standard pump. There is no documentation of a 
trial and failure of the standard pump. 
 
 
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 a pneumatic compression device for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT, abdomen and pelvis; with contrast material(s) (CPT Code 
74177). 
 
You asked the Plan to pre-approve the CT scan. You say that you believe the enrollee meets criteria for the CT 
due to the enrollee being diagnosed with stage 3B adenocarcinoma of the colon in 2017. You state the enrollee 
has surgery, laparoscopic right total colectomy on January 5, 2017, for the colon carcinoma and you believe the 
enrollee is still within the CT scan annual surveillance time-frame of five (5) years. The Plan denied your 
request. The Plan says that follow up imaging is only supported once per year for five years after surgery. The 
Plan states the records do not describe this imaging time frame. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our physician reviewer 
found the CT of the abdomen is approved every 6-12 months for 5 years. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve CT, abdomen and pelvis; with contrast material(s) (CPT Code 74177).  
 
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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Erbitux.

You asked the Plan to pre-approve Erbitux. You say that the requested Erbitux is medically necessary. The
Plan denied your request. The Plan says that the requested Erbitux 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 Erbitux. Our reviewer says that the
requested Erbitux is medically necessary. Our physician reviewer found the enrollee is diagnosed with stage IV
colon cancer, due to liver lesions. The physician would like to treat the enrollee's condition with Erbitux in
regimen with capecitabine and oxaliplatin. Per NCCN compendia, the requested xelox+erbitux is medically
reasonable and necessary for kras wild type metastatic colon cancer.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Erbitux have been met. Therefore, we decided that the Plan has to pre-approve
Erbitux.

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.