Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent taxi transportation for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says the request for transportation is not a covered benefit and is therefore not approved. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve non-emergent taxi transportation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced leg pump device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that the enrollee's lymphedema is not adequately 
controlled with conservative therapies. The Plan denied your request. The Plan says there is no documentation 
of a complete four week trial with a basic device and associated garments. 
 
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 device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation that the enrollee has unique characteristics that would indicate the segmented 
pump over a standard pump. There is no documentation that the enrollee has had 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 an advanced leg pump device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on January 18, 2020 to March 18, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree 
with these charges because there was such a delay in the billing. The Plan denied your request. The Plan says 
the correct coinsurance has been 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $2,404.71. The total amount you are being asked to pay is $480.93 ($2,404.71 x 20% 
coinsurance = $480.93). The correct coinsurance has been applied to the durable medical equipment that was 
provided. Durable medical equipment falls within the durable medical equipment 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 coinsurance for durable medical equipment provided by a participating provider on 
January 18, 2020 to March 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on May 4, 
2020. 
 
You asked the Plan to waive the copayment for the laboratory services. 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 laboratory services on the date of service at issue in this appeal. The 
Plan says that the correct copayment 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 $30 
copayment for Medicare-covered lab services and diagnostic procedures/tests performed in an outpatient 
hospital facility. 
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received laboratory 
services performed in an outpatient hospital facility on May 4, 2020. You have been asked to pay a $30 
copayment for the laboratory services. The laboratory services fall within the Outpatient diagnostic tests 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 laboratory services provided on May 4, 
2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy evaluation (97162) and the 
therapeutic exercises (97110) to be provided by the out of network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested provider is not accepting new patients 
and will no longer be a contracted provider within the Plan's network. The Plan has issued approval for these 
services to be provided by an in-network provider.  
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
physical therapy evaluation (97162) and the therapeutic exercises (97110) to be provided by the out of network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature for a wheelchair.
You asked the Plan to pre-approve the feature. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as 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 a power seat elevation feature for a wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on March 13, 2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says an appropriate modifier was not appended to 
CPT code 93010. 
 
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 asked our coder 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 electrocardiogram. Our reviewer says that CPT code 
93010 does not meet criteria for billing or reimbursement consideration. Our coder found the documentation 
does support the separate service, however a 59 modifier was not appended to CPT 93010, therefore it is not 
eligible for reimbursement. 
 
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 electrocardiogram have not been met. Therefore, we decided that the Plan 
does not have to pay for an electrocardiogram (93010) provided on March 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient surgery services provided 
on February 7, 2020 and February 14, 2020 and the specialist visit on March 5, 2020. 
 
You asked the Plan to waive the copayments for the outpatient surgery services and specialist visit. 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 outpatient surgery services and a 
specialist visit on the dates of service at issue in this appeal. The Plan says that the correct copayments have 
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 $375 
copayment for Outpatient surgery and a $35 copayment for specialist visits.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient 
surgery services on February 7, 2020 and February 14, 2020. You have been asked to pay a $375 copayment 
for each outpatient surgery service. The outpatient surgery services fall within the Outpatient surgery benefit 
category. The file shows that you received a specialist visit on March 5, 2020. You have been asked to pay a 
$35 copayment for the specialist visit. The specialist visit falls within the Physicians/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 copayments for the outpatient surgery services 
provided on February 7, 2020 and February 14, 2020 and the specialist visit on March 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the Keytruda. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says Keytruda is not approved for the member's 
condition. 
 
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 the Keytruda. Our reviewer says that 
the requested use of this drug is not FDA approved or supported by any of the CMS compendia. Our physician 
reviewer found this drug is not 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 Keytruda have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-Melanoma testing. 
 
You asked the Plan to pay for the DecisionDx-Melanoma testing. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this test is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules say that claims for DecisionDx-Melanoma testing will be 
denied when testing does not meet all of the above criteria. 
 
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 DecisionDx-Melanoma testing. Our 
reviewer says that the enrollee is noted to have T4a cutaneous melanoma. The DecisionDx-Melanoma test is 
covered for stage T1 and T2 cutaneous melanomas. Our physician reviewer found the enrollee's melanoma 
does not meet coverage criteria. 
 
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 DecisionDx-Melanoma testing have not been met. Therefore, we decided 
that the Plan does not have to pay for DecisionDx-Melanoma testing.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve echocardiography services.
You asked the Plan to pre-approve the echocardiography services. You say that you would like reconsideration
because you are experiencing constant palpitation causing dizziness and the inability to walk. The Plan denied
your request. The Plan says that you do not meet coverage criteria for this service.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 echocardiography services. Our
reviewer says that the requested items/services are considered medically reasonable and necessary in this case.
Our physician reviewer found an echocardiogram to assess cardiac structure and function is reasonable,
appropriate and considered standard accepted practice in the medical community. Coverage criteria are met
since new or worsening cardiac symptoms including palpitations is a standard covered indication.
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 echocardiography services have been met. Therefore, we decided that the
Plan has to pre-approve echocardiography services.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 6, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on May 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary or reasonable. Our physician reviewer found it is noted that the enrollee has not 
previously taken and medication specifically for osteoporosis. There is no evidence of allergy to, or 
contraindication for, other osteoporosis medications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on January 6, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 lumbar-sacral orthosis rendered on January 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivolumab (Opdivo). 
 
You asked the Plan to pre-approve Opdivo. You say that the enrollee is unable to receive standard 
chemotherapy. The Plan denied your request. The Plan says the enrollee does not have disease progression on 
or after platinum-based chemotherapy. 
 
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 Opdivo. Our physician reviewer found 
that the enrollee has stage IV non-small cell lung cancer. He has no mutations and is PDL1 of less than 1. The 
requested use of Opdivo is not FDA-approved for the enrollee's diagnosis. It is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is 
listed as not indicated, not supported or not recommended in the compendia. The documentation does not 
support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Nivolumab (Opdivo).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexlizet tablets. 
 
You asked the Plan to pre-approve Nexlizet tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Nexlizet tablets are not covered under the enrollee's 
Medicare Part B 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 Nexlizet tablets.  
 
Benefits for Nexlizet tablets 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires daily medical supervision as 
well as 24 hour nursing care for management of vitals, lab and medication management. The Plan denied your 
request. The Plan says that ongoing skilled services can be provided at a lower level of care. 
 
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 
patient is medically stable with no evidence of need for supervision by physical medicine and rehab physician 
or need for acute rehab nursing care. Functionally given his level, he does not require IRF level of therapies. 
The patient may benefit from further physical therapy and occupational therapy but does not require an 
intensive therapy program. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on February 12, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you never had an injection. 
The Plan denied your request. The Plan says the correct copayment has been 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 $40 
copayment for physician/practitioner services/office visits/specialists.  
 
You have been asked to pay a $40 copayment for specialist services. The total amount you are being asked to 
pay is $77.22 ($40 + $37.22 = $77.22). Specialist services fall within the physician/practitioner services/office 
visits/specialists 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 specialist services 
provided by a participating provider on February 12, 2020 on February 12, 2020.