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

 
We decided that the Plan does not have to pre-approve Eylea for the enrollee. 
 
You asked the Plan to pre-approve Eylea. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there was no reason given for why this medication is not appropriate for the 
member. 
 
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 Eylea. Our reviewer says that Eylea is 
not medically reasonable and necessary for the enrollee in this case. The provided records do not show 
evidence the enrollee has tried and failed Avastin. It would be unexpected that the patient would experience 
less effectiveness or more side effects if using Avastin over the prescribed Eylea as both anti-VEGF drugs were 
compared in the literature showing essentially equal risk and benefit. Our physician reviewer found that the 
 
 
enrollee's condition does not meet step therapy criteria for Eylea. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve protective outer surface coverings, and a right transtibial 
prosthesis. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says Medicare 
does not allow separate payment for items still under warranty. 
 
The Plan must follow Medicare rules. Medicare rules say that lower limb prostheses are only covered under 
certain medical indications. 
 
We looked at the file and Medicare rules. The records provided do not indicate the enrollee requires protection 
against unusually harsh environmental situation. The documentation also shows that the requested right 
prosthesis is still under warranty. Based on this information, we decided that Medicare rules for coverage of the 
requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve protective 
outer surface coverings, and a right transtibial prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluations (D0140 x 2) provided from April 
1, 2020 to June 11, 2020. 
 
You asked the Plan to pay for the limited oral evaluations. You say that you feel and broke 2 teeth. You say 
that you went to a participating provider. initially. You say that they were unable to help you due to Covid-19. 
You also say that it was difficult to find someone in network that could help you. The Plan denied your request. 
The Plan says 1 limited oral evaluation per calendar year is covered. The Plan says the frequency limit has been 
exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 limited oral 
evaluation per calendar year has been exceeded. The record shows that you received a limited oral evaluation 
on March 24, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluations 
(D0140 x 2) provided from April 1, 2020 to June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper and lower dentures. 
 
You asked the Plan to pre-approve the requested dentures. You say that the dentures you received were more 
uncomfortable than your broken ones. The Plan denied your request. The Plan says your 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.  
 
We looked at the file, and Medicare rules. The records show that you received complete upper and lower 
dentures on December 2, 2019. Your plan only covers dentures once every 5 years. Based on this information, 
we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pre-approve complete upper and lower dentures.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract surgery you had on May 7, 
2020. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you were never told there 
would be a second charge for a second surgery. The Plan denied your request. The Plan says you were charged 
this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient surgery.  
 
Records show that you had cataract surgery on your left eye on March 10, 2020.  You paid your surgery 
copayment for that procedure.  You then had surgery on your right eye on May 7, 2020. You have been asked 
to pay a $275 copayment for the cataract surgery. This is a completely separate procedure and a second 
copayment appropriately applied. 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 cataract surgery 
you had on May 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care you received from June 8, 2020, to June 11, 2020.You asked the Plan to waive the copayment forthe inpatient hospital services. You say that you cannot afford this copayment.The Plan denied your request. The Plan says you were charged this copayment correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment per day for days 1-6 for inpatient hospital care. You have been asked to pay a $300 copayment per day for days the three days you were an inpatient in the hospital 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 forinpatient hospital care you received from June 8, 2020, to June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 2, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 services were not referred by a network provider or rendered in a participating 
facility. These services are 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 did not pre-approve the 
physician?s services. 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 physician's services provided on June 2, 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 medical record is reviewed in its entirety.  
You have stabilized medically and have been receiving skilled rehab services in an inpatient rehabilitation 
facility (IRF). You continue to require skilled nursing and/or skilled therapy services on a daily basis. You are 
making slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required.  
You can continue to received skilled rehab services at the current IRF until step down to a community setting. 
There are no services offered at a SNF that are not offered at an IRF. 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 pre-approve medical services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you need a follow up for your vertigo. The Plan 
denied your request. The Plan says there are in-network providers available. 
 
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 otolaryngology services at issue in this appeal. We found no exception that 
would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have 
to pre-approve medical services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to provide eye exam (92014), scanning computerized ophthalmic diagnostic 
imaging (92134), eye injection (67028) and injection (J9035). 
 
You asked the Plan to provide eye exam, diagnostic imaging and injections. You say that you would like to 
continue to see your previous provider instead of starting all over again with a new doctor that doesn't know 
your condition. The Plan denied your request. The Plan says that the service is available in-network, you were 
instead redirected to the preferred provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees? needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 provide eye exam, diagnostic imaging and 
injections. Our reviewer says that the service is medically necessary. Our physician reviewer found you are 
receiving a treatment regimen by a contracted provider that requires linear follow up care.  It is in your best 
interests to continue to receive injections at the current provider.  Experience with prior injections, certainly 
can have an impact on the outcome. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of eye exam, diagnostic imaging and injections have been met. Therefore, we 
decided that the Plan has to provide eye exam (92014), scanning computerized ophthalmic diagnostic imaging 
(92134), eye injection (67028) and injection (J9035).  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spinal Surgery/ Decompression Surgery. 
 
You asked the Plan to pre-approve Spinal Surgery/ Decompression Surgery. 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 Spinal Surgery/ Decompression 
Surgery. 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 back pain. The requested spacer device 
remains experimental for the treatment of spinal stenosis. More research is needed to show safety. 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 Spinal Surgery/ Decompression Surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Spinal Surgery/ Decompression Surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and panoramic x-ray 
provided on July 23, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you didn't 
know the dentist was doing services that weren't covered. You say that they should have checked to see if it 
was covered before performing the services. The Plan denied your request. The Plan says a comprehensive oral 
evaluation is only covered once every 36 months and the panoramic x-ray is not a covered benefit. 
 
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, you also have a maximum benefit of 
one comprehensive oral exam every 36 months. The Plan paid for a comprehensive oral evaluation provided on 
March 5, 2019, which exhausted your benefit. The panoramic x-ray is not a covered benefit. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation and panoramic x-ray provided 
on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 9, 2020.You asked the Plan to pay for the physician's services.The Plan denied your request. The Plan says services rendered by non-participating providers require 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 did not pre-approve the physician's services.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 physician's services provided on June 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 100mg/5l Vectibix vial (J9303). 
 
You asked the Plan to pre-approve the Vectibix. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says the member does not meet criteria for the 
Vectibix. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the Vectibix. Our reviewer says that the 
requested use is not FDA approved. Our physician reviewer found 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 the Vectibix have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 100mg/5l Vectibix vial (J9303).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services provided to the enrollee on November 6, 
2018. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim was not filed within the required timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for this service was not filed until April 27, 2020. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for vision services provided to the enrollee on November 6, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit securement kit for a power wheelchair. 
 
You asked the Plan to pre-approve a transit kit. The Plan denied your request. The Plan says the transit option 
is considered non-medical in nature. 
 
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. Medicare does not 
cover equipment used for comfort or for convenience. Therefore, we decided that the Plan does not have to pre-
approve a transit securement kit for a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee. 
 
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 the specimen type collected is incorrect for the billed codes; therefore, the code cannot be 
verified. 
 
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 the denied codes is: 
 
CPT 80157: 
Carbamepazine; free 
 
CPT 80159: 
Clozapine 
 
CPT 80162: 
Digoxin; total 
 
CPT 80173: 
Haloperidol 
 
CPT 80177: 
Levetiracetam 
 
CPT 80201: 
Topiramate 
 
 
 
 
HCPCS G0483: 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 
 
CPT 80307: 
Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by 
instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
We find that the denied codes are not supported in the medical record. Specifically, there is no valid physician 
order for these services, and the services were done by urine sampling rather than blood sampling. 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 drug testing services provided to the enrollee.