Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye surgery provided. 
 
You asked the Plan to waive the copayment for the eye surgery. You say that you would like reimbursement. 
The Plan denied your request. The Plan says that the claim processed 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 $300 
copayment for Outpatient surgery at an ambulatory surgical center.  
 
You have been asked to pay a $300 copayment for the eye surgery. The eye surgery falls within the Outpatient 
surgery at an ambulatory surgical center 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 copayment 
for the eye surgery provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. 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 Imfinzi. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found Durvalumab (Imfinzi) is FDA approved 
for the treatment of unresectable stage 3 non-small cell lung cancer in adults whose disease has not progressed 
following concurrent platinum-based chemotherapy and radiation therapy. This enrollee has yet had follow-up 
imaging documenting stable or improved disease. The service is not reasonable or medically 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 Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves. 
 
You asked the Plan to pre-approve radiofrequency ablation of the genicular nerves. 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 radiofrequency ablation of the genicular 
nerves. 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 chronic bilateral knee pain due to 
osteoarthritis. The enrollee takes Percocet, Xtampza, Meloxicam, and Cymbalta for pain. The enrollee has had 
RFA of her genicular nerves in 2017 and 2019 with good results. This is an experimental/ investigational 
procedure that is the subject of on-going clinical trials. 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 radiofrequency ablation of the genicular nerves have not been met. Therefore, 
we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for laboratory tests provided on May 27, 
2020, and June 5, 2020. 
 
You asked the Plan to waive the copayments for laboratory tests. You say that you disagree with the charges 
because you thought copayments were waived due to COVID-19. The Plan denied your request. The Plan says 
the claims were processed correctly and you are being charged the correct 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 $20 
copayment for laboratory tests.  
 
You received laboratory tests on May 27, 2020. Laboratory tests are not included in the copayment waiver due 
to COVID-19. Therefore, you are responsible to pay the $20 copayment.  
 
You received laboratory tests on June 5, 2020. Laboratory tests are not included in the copayment waiver due 
to COVID-19. Therefore, you are responsible to pay the $20 copayment. 
 
The total amount you owe is: $40.  
 
You have been asked to pay the total copayment amount of $40 for laboratory tests. Laboratory tests 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 laboratory tests provided on May 27, 2020, and June 5, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer 
found the enrollee continues to require skilled nursing and/or skilled therapy services on an intermittent basis. 
Although the enrollee is making slow progress with therapy, there is no indication that transfer to a skilled 
nursing facility is required. The enrollee can continue to received skilled rehab services at the current IRF or 
receive further care at a lower level of care. The documentation indicates the enrollee will require custodial 
care going forward due to cognitive impairment. There are no services offered at a SNF that are not offered at 
an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy (97124). 
 
You asked the Plan to pay for massage therapy. You say that according to the terms of your policy you are 
covered for massage therapy and acupuncture. You have spoken with representatives on 2 separate occasions 
and both have agreed that you are covered. The Plan denied your request. The Plan says there was no 
preauthorization for acupuncture services or massage therapy and no medical criteria submitted for review. 
This service is not covered under the plan benefits. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for massage therapy (97124).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis 0.05%. 
 
You asked the Plan to pre-approve Restasis. You say that this is medically necessary for your condition. The 
Plan denied your request. The Plan says this medication does not fall under Part B benefits. 
 
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 Restasis 0.05%.  
 
Benefits for Restasis 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued use of a CPAP machine and a heated 
humidifier. 
 
You asked the Plan to pre-approve the continued use of a CPAP machine and a heated humidifier. You say that 
you do use the machine but fell in November and hit your head. You say that, since that injury, you have found 
yourself falling asleep in your chair. You say that it?s not your fault that your only sleep for 3 hours before you 
have to urinate. You say that when you go back to sleep, its hard and not often for 4 hours.  
You say that you and your doctor believe this device works for you. The Plan denied your request. The Plan 
says the enrollee's previous use of the device has been inconsistent, and the machine was used for more than 4 
hours only 20% of the time. The Plan says that the enrollee is not sufficiently using the machine to receive the 
clinical benefit. 
 
The Plan follows Medicare rules. Medicare rules say that continued use of a CPAP machine is covered when 
certain indications have been met.  
 
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 continued use of a CPAP machine 
and a heated humidifier. Our reviewer says that the criteria for coverage have not been met. Our physician 
reviewer found usage of the device does not meet the minimum Medicare criteria of at least 4 hours per night 
for at least 70% of nights and is insufficient to provide clinical benefit.  The medical records do not indicate a 
plan for addressing the compliance issue.  CPAP is therefore considered not medically 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 continued use of a CPAP machine and a heated humidifier have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the continued use of a CPAP machine 
and a heated humidifier.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the request for the inpatient rehabilitation level of care exceeds your 
medical needs. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for COVID 19 infection and a 
kidney stone. You have been discharged to skilled nursing family where therapy services are provided. Your 
medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your condition does not meet Medicare criteria for IRF 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis. We decided that the Plan 
does not have to pre-approve a CT scan of the chest.  
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the services are 
necessary. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis.  
 
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 a CT scan of the abdomen and pelvis. 
Our reviewer says that the services are medically necessary. Our physician reviewer found the evaluation of the 
liver has been equivocal with several lesions changing in CT conspicuity and despite a negative biopsy close 
CT surveillance is indicated since neuroendocrine tumors have a propensity to metastasize to the liver.  The 
most recent CT studies of 2019 and August 24, 2020 show persistent abnormalities. Since the original tumor 
was in the rectum it is reasonable to approve the requested CT of the abdomen and pelvis. 
 
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 CT scan of the abdomen and pelvis have been met. Therefore, we decided that 
the Plan has to pre-approve a CT scan of the abdomen and pelvis.  
 
We also decided that the Plan does not have to pre-approve a CT scan of the chest. 
 
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 a CT scan of the chest. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found this enrollee had treatment in 
January 2018 and has no evidence of metastatic disease on chest CT. The request for CT of the chest should be 
denied 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 a CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the chest. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a breast prosthesis/mastectomy sleeve (L8010). 
 
You asked the Plan to pre-approve the mastectomy sleeve. You say that this was covered before under previous 
plan. The Plan denied your request. The Plan says this durable medical equipment is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the mastectomy sleeve have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a breast prosthesis/mastectomy sleeve (L8010).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on July 23, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 95907 is not supported. 
 
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 95907 is nerve conduction studies; 1-2 studies. 
 
We find that CPT code 95907 is not supported in the medical record. Specifically, there is no documentation of 
1-2 nerve conduction studies. 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 pay for the testing services 
rendered on July 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 17, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring 
provider is out-of- network. 
 
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 had network providers 
available who could have provided 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 lab work provided on September 17, 2020 by an 
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon. 
 
You asked the Plan to pre-approve these services. You say that you want to see this doctor. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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 referral to an out-of-network orthopedic surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove the therapeutic continuous glucose monitor or CGM 
(A9278NU and A9276NU) 
 
You asked the Plan to preapprove the CGM. You say that the enrollee is testing more than four times a day. 
The Plan denied your request. The Plan says the member is not using insulin, so coverage criteria are not met. 
 
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 indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM 
have not been met. Therefore, we decided that the Plan does not have to preapprove the therapeutic continuous 
glucose monitor or CGM (A9278NU and A9276NU).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has osteoarthritis of both 
knees, confirmed on imaging studies. She has not tried and failed the Plan's required drugs of Orthovisc, 
Synvisc, or Synvisc One. The records do not show that the required drugs would be contraindicated or less 
effective; therefore, the Hyalgan is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyalgan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the special treatment, aquablation therapy (0421T). 
 
You asked the Plan to pre-approve the special treatment, aquablation therapy. You say that please consider this 
request for preauthorization of benefits to treat your patient. The enrollee is an ideal candidate for transurethral 
waterjet ablation. The Plan denied your request. The Plan says the requested services is unproven and is 
considered experimental and/or investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the special treatment, aquablation therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the special treatment, aquablation therapy (0421T).