Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy, 60 minutes with patient (CPT code 90837) 
provided to the enrollee on September 16, 2020, by an out-of-network provider. 
 
You asked the Plan to pay for the services. You say that the enrollee was seen by oncology and it was decided 
that the enrollee needed further psychological evaluation. The Plan denied your request. The Plan says the 
enrollee self-directed out-of-network. The Plan states this provider is out-of-network, the services were not 
referred by a network provider and the services were not urgent or emergent, nor were they approved in 
advance. 
 
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 
psychotherapy, 60 minutes with patient (CPT code 90837) provided to the enrollee on September 16, 2020, by 
an out-of-network provider.
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 in the Medicare rules section. 
 
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 health plan's denial should be upheld. 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. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient hospital 
setting on October 5, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you feel that you are not responsible 
for these drugs, specifically the nitroglycerin and ticagrelor. The Plan denied your request. The Plan says the 
drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a 
Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under 
Medicare Part B. 
 
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 pay for the self-administered drugs 
provided in an outpatient hospital setting on October 5, 2020.  
 
Benefits for the self-administered drugs 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 a freestyle libre CGM. 
 
You asked the Plan to pre-approve the freestyle libre CGM. You say that you would like reconsideration 
because the member has been using a CGM for two years. The Plan denied your request. The Plan says a CGM 
is not covered in the member's individual medical circumstances according to Medicare rules. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the freestyle libre CGM. Our reviewer 
says that the member does not meet Medicare criteria for coverage. Our physician reviewer found we are not 
given enough information to say that the member is truly having severe lows and is checking blood glucose 
four or more times a day. 
 
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 freestyle libre CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a freestyle libre CGM.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a vision service (V2799), anti-
reflective lens coating (V2750), contact lenses (V2500), and trifocal eyeglass lenses (V2303) received on 
November 9, 2020. 
 
You asked the Plan to pay an additional amount for a vision service, anti-reflective lens coating, contact lenses, 
and trifocal eyeglass lenses. You say that you want the plan to cover these items. The Plan denied your request. 
The Plan says the benefits were applied correctly. The benefit allowance of $150 was applied to the purchase 
leaving a member responsibility of $420. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $150 allowance, then you are responsible for paying the 
difference.
 
We looked at the file and the Plan's rules. the benefits were applied correctly. The benefit allowance of $150 
was applied to the purchase leaving a member responsibility of $420. Based on this information, we decided 
that the Plan's rules for coverage of a vision service, anti-reflective lens coating, contact lenses, and trifocal 
eyeglass lenses have not been met. Specifically, the record shows that you had exhausted your eyewear benefit 
maximum of $150, and are responsible for paying the remainder of $420. Therefore, we decided that the Plan 
does not have to pay an additional amount for a vision service (V2799), anti-reflective lens coating (V2750), 
contact lenses (V2500), and trifocal eyeglass lenses (V2303) received on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tissue transfer (14301) and debridement (11012) provided on 
May 7, 2020. 
 
You asked the Plan to pay for tissue transfer and debridement. You say that these codes are supported. The 
Plan denied your request. The Plan says these codes are not documented. 
 
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 14301 is  adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm, and 11012 is debridement including removal of foreign material at the 
site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, 
muscle fascia, muscle, and bone. 
 
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 tissue transfer and debridement. Our 
reviewer says that these codes are not supported. Our physician reviewer found the operative report does not 
include documentation of sections of healthy skin and other tissues transferred to the adjacent skin defect, 
which is indicated the description for CPT 14301. Code 11012 is not the appropriate code to report for 
hardware removal. There is a more appropriate code to report for this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tissue transfer and debridement have not been met. Therefore, we decided that 
the Plan does not have to pay for tissue transfer (14301) and debridement (11012) provided on May 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ceftriaxone injections by IV. 
 
You asked the Plan to pre-approve ceftriaxone injections (J0696, 99602, 99601). You say that this injection 
helps with the enrollee's medical condition. The Plan denied your request. The Plan says this drug infusion is 
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 ceftriaxone injections by 
IV.  
 
Benefits for ceftriaxone injections (J0696, 99602, 99601) 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transport from dialysis to 
residence provided on May 27, 2020. 
 
You asked the Plan to pay for the non-emergent ambulance transport. You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the enrollee appears to be able to sit in a wheelchair or 
recliner therefore alternatives to transport may include a wheelchair van or a private vehicle. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file and Medicare rules. The record shows the enrollee did not require the expertise of trained 
personnel or the equipment available only on an ambulance in order to effectuate a safe transport. The enrollee 
could have been safely transported by another type of vehicle. You did not request prior authorization. Based 
on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transport 
have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance 
transport from dialysis to residence provided on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the additional 
periapical x-ray (D0230), and the panoramic x-ray (D0330) provided on November 11, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says 1 comprehensive oral evaluation is covered every 3 calendar years. The Plan says 
that 1 periapical x-ray is covered per year. The Plan says 1 panoramic x-ray is covered every 5 years. The Plan 
says the frequency limits for these services have been exceeded. The Plan says that the provider in this case is 
out of network. The Plan also says that out of network providers may bill you for any amount greater than the 
payment made by the Plan to the provider. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
the frequency limitations have been exceeded. The record shows that the Plan paid for a comprehensive oral 
evaluation and panoramic x-ray that you received on March 13, 2019. The record also shows that the Plan paid 
for the initial periapical x-ray that you received on the date of service in this case. Additionally, out of network 
providers may bill you for any amount greater than the payment made by the Plan to the provider. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the additional 
periapical x-ray (D0230), and the panoramic x-ray (D0330) provided on November 11, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Panitumumab, 5-FU, Leucovorin IV, Oxaliplatin, Palonosetron, 
Dexamethasone, and Fosaprepitant IV. 
 
You asked the Plan to pre-approve Panitumumab, 5-FU, Leucovorin IV, Oxaliplatin, Palonosetron, 
Dexamethasone, and Fosaprepitant IV. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says that the requested drugs are 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 Panitumumab, 5-FU, Leucovorin IV, 
Oxaliplatin, Palonosetron, Dexamethasone, and Fosaprepitant IV. Our reviewer says that the documentation 
supports that the requested drugs are medically reasonable and necessary. Our physician reviewer found the 
enrollee has rectal cancer. The documentation does not support that the requested drugs are FDA approved for 
the enrollee's diagnosis. However, the requested use is supported in a major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. Although not  preferred regimen, it is an acceptable 
alternative regimen based on ESMO guidelines even with enrollees that have progressed on prior epidermal 
growth factor receptor (EGFR) therapy. Therefore, the requested drugs are safe, effective, reasonable, and 
necessary for the 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 Panitumumab, 5-FU, Leucovorin IV, Oxaliplatin, Palonosetron, 
Dexamethasone, and Fosaprepitant IV have been met. Therefore, we decided that the Plan has to pre-approve 
Panitumumab, 5-FU, Leucovorin IV, Oxaliplatin, Palonosetron, Dexamethasone, and Fosaprepitant IV.  
 
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 pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member currently does not have any daily nursing or therapy need. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a replacement prosthesis with an out-of-
network provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says medically necessary care is 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 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 for a replacement prosthesis with an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to you by an out-of-network 
provider on September 18, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
not approved in advance. 
 
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 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 lab services provided to you by an out-of-network provider 
on September 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on October 15, 2020. 
 
You asked the Plan to pay for the ConfirmMDx testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this testing is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ConfirmMDx is covered for males aged 40 to 85 
years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being 
considered for a repeat biopsy due to persistent or elevated cancer-risk factors. 
 
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 ConfirmMDx testing. Our reviewer says 
that the available documentation does not indicate that the enrollee is being considered for a repeat biopsy. Our 
physician reviewer found the elements of the local coverage determination are not satisfied and the requested 
service cannot be recommended. 
 
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 ConfirmMDx testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the ConfirmMDx testing provided on October 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need this 
transportation to get to appointments. The Plan denied your request. The Plan says that only twenty trips are 
allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of twenty (20) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0156 and S9122) provided on 
August 17, 2020, through August 21, 2020. 
 
You asked the Plan to pay for the home health services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says there is insufficient evidence to verify the 
billed services. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Additionally, the documentation submitted does not include any evidence that these home health 
services were rendered on the billed date of service. Therefore, we decided that the Plan does not have to pay 
for home health services (G0156 and S9122) provided on August 17, 2020, through August 21, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has 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 that they will not cover these services. 
 
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. The Plan has not forwarded any records to substantiate their denial. Therefore, 
we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and 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.