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

We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary for enrollee's 
condition. The Plan denied your request. The Plan says the triple regimen is not supported by Medicare 
standards. 
 
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 Keytruda. Our reviewer says that the 
requested treatment is investigational. Keytruda is not FDA approved for the requested use in ovarian cancer. 
The requested use is not supported in any of the CMS approved compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the discarded amount of decitabine during an injection/infusion 
provided on June 4, 2020 billed with code J0894-JW. 
 
You asked the Plan to pay for the discarded decitabine. You say that this claim was correctly billed and should 
be paid. The Plan denied your request. The Plan says that it was decided to make payment for all services due 
to support in the medical record, aside from the 16 units of J0894-JW. The documentation submitted do not 
include medical records for the billed date of service; therefore, the billed service cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that payment can be made for discarded amount of 
unused medication up to the amount of the drug or biological as indicated on the vial or package label.  
 
In this case, 34 units of J0894 were used and payment was made for this amount. The medical record 
corroborates that this dosage was provided. The claim indicates that the NDC package number for the drug 
administered was 59148-0046-70. This package include a single 50mg vial and each unit of J0894 represents 
one mg. Since there is documentation that only 34mg were used, billing another 16mg, or 16 units, for the 
discarded amount of the drug is appropriate in this case. Therefore, we decided that the Plan has to pay for the 
discarded amount of decitabine during an injection/infusion provided on June 4, 2020 billed with code J0894-
JW.  
 
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: 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. 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 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 based on the documentation provided, the health plan's denial should be upheld. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's 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 acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a pulmonary stress test (94618) received 
on July 13, 2020, for myocardial perfusion imaging (78452), a Regadenoson injection (J2785), and a 
Technetium TC-99m sestamibi dose (A9500) received on July 16, 2020, and for a CT scan of the thorax 
(71250) received on July 27, 2020. 
 
You asked the Plan to waive the cost-sharing for a pulmonary stress test, myocardial perfusion imaging, a 
Regadenoson injection, a Technetium TC-00m sestamibi dose, and a CT scan of the thorax. You say that you 
were not told there would be any extra charges involved in these tests or treatments. The Plan denied your 
request. The Plan says the correct cost-sharing was 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 $110 
copayment for each Medicare-covered radiological diagnostic service, a $20 copayment for Medicare-covered 
non-radiological diagnostic services, and 20% coinsurance for each Medicare-covered Part B drug.  
 
You have been asked to pay two $110 copayments each for myocardial perfusion imaging and a CT scan of the 
thorax. You have also been asked to pay a $20 copayment for a pulmonary stress test. A pulmonary stress test, 
myocardial perfusion imaging, and a CT scan of the thorax fall within the "Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies" benefit category. You have been asked to pay $47.50, or 20% of the 
Medicare-allowed amount of $237.48, for a Regadenoson injection, and $48.68, or 20% of the Medicare-
allowed amount of $243.40, for a Technetium TC-00m sestamibi dose. A Regadenoson injection and a 
Technetium TC-00m sestamibi dose fall within the "Medicare Part B Prescription Drugs" 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-sharing for a pulmonary stress test (94618) received on July 13, 2020, 
for myocardial perfusion imaging (78452), a Regadenoson injection (J2785), and a Technetium TC-99m 
sestamibi dose (A9500) received on July 16, 2020, and for a CT scan of the thorax (71250) received on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayment charged for vision services provided on 
September 18, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the services billed by your 
provider and the Plan contract agreement. 
 
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 $40 
copayment for vision services. 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 $40 copayment charged for vision services provided on 
September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer. 
 
You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 a Superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the spacer 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 a Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve a partial upper denture. You say that the item is necessary. The Plan denied 
your request. The Plan says the benefit has been exhausted. 
 
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 one partial 
denture every five plan years. 
 
We looked at the file and Medicare rules. You received an upper partial denture on August 3, 2018. Based on 
this information, we decided that the Plan's rules for coverage of a partial upper denture have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
June 4, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter.  
 
 
 
 
Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating 
site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional 
Shortage Area (HPSA) located in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis 
(L0650) provided to the enrollee on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air purifier. 
 
You asked the Plan to pre-approve air purifier. You say that this device would help with your breathing issues. 
The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this 
item is not primarily medical in nature and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an air purifier.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that you had surgery and need to be in a facility. The 
Plan denied your request. The Plan says you do not require skilled nursing or rehab services only on an 
inpatient basis. 
 
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 services. Our physician reviewer 
found that you do not require nursing services of a skilled professional nurse to safely and effectively provide 
medically necessary treatment in a SNF. You continue to need acute hospital care at this time, and are not 
ready for transfer to a rehab program. Your creatinine is not near baseline and your renal function is being 
managed and evaluated for etiology of elevation. You do not have complex wound care. Your functional level 
does not require therapy services of a qualified therapist to provide medically necessary treatment on a daily 
basis. You are already ambulating 175 feet with therapy. At this time you do not require admission to a SNF. 
 
 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zolpidem Tartrate. 
 
You asked the Plan to pre-approve Zolpidem Tartrate. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee has a medical only policy which does not include Part D 
prescription coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Zolpidem Tartrate.  
 
Benefits for Zolpidem Tartrate 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia (01936) provided on May 22, 2020. 
 
You asked the Plan to pay for anesthesia. You say that this service was provided by a different provider than 
the service is was denied against. The Plan denied your request. The Plan says that the billed CPT code, 01936, 
has an NCCI edit with 72275, which was previously paid. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Though the Plan states this denied for NCCI edits, the case file does not show 
that these services were performed by the same provider. Therefore, we decided that the Plan has to pay for 
anesthesia (01936) provided on May 22, 2020.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on April 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-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 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 to the enrollee by an out-of-network provider 
on April 20, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (CPT 55866) provided to the enrollee on March 12, 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 that procedure code CPT 55866 is not supported by the medical records submitted. 
 
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 55866 is 
"Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when 
performed." 
 
We asked our coding 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 services. Our reviewer says that the services at issue in this case 
were supported by the medical records. Our coding reviewer found the operative report include enough detail to confirm 
the reported modifier 22 (increased procedural services).  This code would be reported when substantially greater service 
than typically required is performed.  Operative report documents, "THE PATIENT HAD A VERY LARGE PROSTATE 
WITH RESULTANT LARGE BLADDER NECK. THIS WOULD REQUIRE RECONSTRUCTION. DUE TO THE 
LARGE SIZE, THE CASE IS CONSIDERED COMPLEX DUE TO RESULTANTRECONSTRUCTION, COMPLEX 
DISSECTION AND INCREASE IN OPERATIVE TIME BY APPROX 50%". The surgeon reports why increased 
procedural services were performed, as well as the time added to the procedure performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules 
for coverage of the services have been met. Therefore, we decided that the Plan has to pay for surgical services (CPT 
55866) provided to the enrollee on March 12, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 3, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because you 
were out of the Plan's service area and required medical attention. The Plan denied your request. The Plan says 
these services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on June 3, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PureWick external female catheter incontinence 
supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you qualify for these supplies and other 
insurance companies did not deny this. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve PureWick external female 
catheter incontinence supplies.
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 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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does 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 this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
 
 
 
 
 
 
 
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.