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

 
We decided that the Plan has to pre-approve Udenyca. 
 
You asked the Plan to pre-approve Udenyca. You say that the drug in dispute is medically necessary. The Plan 
denied your request. The Plan says that a Keytruda/Padcev chemotherapy regimen is not compendia supported. 
 
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 Udenyca. Our reviewer says that the 
criteria for coverage of Udenyca have been met. Our physician reviewer found the use of Udenyca is FDA-
approved for the enrollee's diagnosis, as he is high risk for neutropenic fever given prior chemotherapy and his 
current regimen. The use of Udenyca is not listed as being not indicated, nor supported, or not recommended in 
any of the compendias. The documentation provided supports that Udenyca 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 Udenyca have been met. Therefore, we decided that the Plan has to pre-approve 
Udenyca.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
enrollee is not on short-acting insulin. 
 
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are only covered under 
certain medical indications.  
 
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 requested device. Our physician 
reviewer found that the enrollee has a past medical history of type II diabetes mellitus. He is on metformin and 
recently has been started on Ozempic, but he is not on insulin. There is no documentation that the enrollee is 
performing frequent (four or more times per day) glucose testing, or that the enrollee is insulin-treated with 
multiple daily injections. Therefore, the requested device is not medically reasonable and necessary to treat 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 the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3310) and a prefabricated post 
and core in addition to crown (D2954). 
 
You asked the Plan to pre-approve the endodontic therapy and prefabricated post and core. You say that these 
services are recommended. The Plan denied your request. The Plan says these services are not covered. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
endodontic therapy (D3310) and a prefabricated post and core in addition to crown (D2954).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve a power wheelchair. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that notes do not show that the enrollee is unable to walk 
around. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says 
that a power wheelchair is not medically reasonable and necessary for the enrollee in this case. There is no 
documentation that the patient has a personal mobility deficit that impairs participation in mobility related 
activities of daily living (MRADLs). There is no documentation that the patient's mobility deficit cannot be 
helped by the use of a walker, cane or manual wheelchair. There is no documentation that the patient can safely 
operate a power mobility device. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for a power wheelchair. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray and extraction on May 7, 2020. 
 
You asked the Plan to pay for the intraoral x-ray and extraction. You say that your regular dentist covered by 
Medicare went out of business. You say that you had an emergency and had to go to this dentist. The Plan 
denied your request. The Plan says payment cannot be issued for services performed by a provider who has 
opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the intraoral x-ray and extraction on May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided February 10, 
2020. 
 
You asked the Plan to pay for the sedation service. You say that the enrollee had multiple exams on this date of 
service. Please reconsider for processing. The Plan denied your request. The Plan says payment may not be 
made by A/B MACs (B) for these services when they are provided to hospital inpatients or patients in a 
hospital outpatient department. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. All services provided to the enrollee will be paid under the global facility claim. Payment for the 
sedation service would have been included under the facility claim. Payment for the sedation services is the 
responsibility of the facility or hospital.  Therefore, we decided that the Plan does not have to pay for moderate 
sedation services (99153) provided February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on March 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that you did not know that the member had this 
specific plan due to the member presenting a different card. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
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 outpatient services provided on March 5, 2020 by 
an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a catheter ablation procedure, non-cardiac, 
endovascular (C1888) performed on May 6 and June 3, 2020. 
 
You asked the Plan to waive the copayments for a catheter ablation procedure. You say that you are overpaying 
for a service you found to be substandard. The Plan denied your request. The Plan says the correct copayment 
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 $225 
copayment for each outpatient surgery and/or service.  
 
You have been asked to pay $450, or a $225 copayment each for 2 procedures, for a catheter ablation 
procedure. A catheter ablation procedure falls within the "Outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for a catheter ablation procedure, non-cardiac, endovascular (C1888) performed on 
May 6 and June 3, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on December 11, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for 
these services. 
 
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 specialist services provided on December 11, 2019 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0481 and 80307 provided on 
December 30, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 find that CPT codes G0481 and 80307 are not supported in the medical record. Specifically, the 
documentation submitted did not include a valid physician order/lab requisition form or medical records signed 
by the ordering physician stating exactly what tests were to be performed. In addition, the submitted lab order 
includes a custom panel however, does not identify screening test was ordered. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing coded G0481 and 80307 provided on December 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on February 
23, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the 
ambulance services 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 ambulance services 
provided on February 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you cannot go too far so you would like to 
see this out-of-network provider. 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 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 
specialist services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroplasty services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve knee arthroplasty services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by 
a 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 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 
knee arthroplasty services to be provided by an out of network (OON) provider.
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 the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found pembrolizumab is not FDA approved for 
the treatment of cholangiocarcinoma or supported by major drug compendia. Peer reviewed medical literature 
suggest that pembrolizumab may be safe and tolerable in enrollee with hepatobiliary cancers regardless of PD-
L1 expression but responses are limited and was a phase II trial. Other lines of therapy may be more 
efficacious. The service is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services received on May 19, 2020. 
 
You asked the Plan to pay for the vision services. You say that you disagree with the plan's decision. The Plan 
denied your request. The Plan says the claim has been processed correctly per your plan benefits. 
 
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 anything 
over $3,000 for out-of-network services per calendar year. The plan will only reimburse a maximum of $3,000 
for out-of-network services. 
 
You have been asked to pay the remainder after $3,000 for the vision services. The vision services fall within 
the out-of-network 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 pay for the vision services received on May 
19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 2, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network 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 
physicians 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 laboratory services provided on April 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care office visit provided on 
September 25, 2019. 
 
You asked the Plan to waive the copayment for office visit. You say that you are being charged for a screening 
but do not believe that this service was rendered. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct. 
 
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 $10 
copayment for primary care office visit. Please note that you are being charged a copayment for the office visit, 
and do not have any cost-sharing responsibility for the screening service you received during the visit. 
 
You have been asked to pay $10 copayment for office visit. Office visit falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits 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 a primary care office visit provided on September 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the patient lift provided to the enrollee on February 3, 2020. 
 
You asked the Plan to pay for the patient lift. The Plan denied your request. The Plan says that there is no order 
for this item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid a physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the patient lift provided to the enrollee on February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown for tooth #12. 
 
You asked the Plan to pre-approve the requested crown. You say that tooth #12 is fractured. The Plan denied 
your request. The Plan says the service is allowed once every 60 months. 
 
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 the Plan rules. The documentation shows that the requested crown for tooth #12 was 
previously provided on July 16, 2020. The enrollees plan only covers one crown per tooth once every 60 
months. Based on this information, we decided that the Plan's rules for coverage of the crown have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a dental crown for tooth #12.