Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy (77385) provided from 
May 27, 2020, to July 23, 2020. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that you were told there would not 
be a copayment for radiation therapy. The Plan denied your request. The Plan says this processed 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 $60 
copayment for each visit for radiation therapy.  
 
You have been asked to pay a $60 copayment for each radiation therapy visit. 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 radiation therapy (77385) provided from May 27, 2020, to July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for comprehensive medical examination and 
evaluation eye exam (92004) 
 
You asked the Plan to waive the copayment for the eye exam. You say that you had cancelled the September 7, 
2019 appointment and they gave you the March 17, 2020 appointment. The Plan denied your request. The Plan 
says this claim has been processed correctly per the 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 $35 
copayment for Medicare covered specialist services to diagnose and treat conditions of the eye.  
 
You have been asked to pay $35 copayment for the eye exam. the eye exam falls within the Vision care 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 comprehensive medical examination and 
evaluation eye exam (92004)
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic, prophylactic, or diagnostic injection, 
chemotherapy administration, Granisetron Hydrochloride injection, and Azacitidine injection provided on May 
15, 2020. 
 
You asked the Plan to pay for the therapeutic, prophylactic, or diagnostic injection, chemotherapy 
administration, Granisetron Hydrochloride injection, and Azacitidine injection. You say that hospice was only 
effective from February 21, 2020, to May 1, 2020. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 1, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the therapeutic, 
prophylactic, or diagnostic injection, chemotherapy administration, Granisetron Hydrochloride injection, and 
Azacitidine injection provided on May 15, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) computed tomography 
(CT) scan from skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET CT scan from skull base to mid-thigh. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 a PET CT scan from skull base to mid-
thigh. Our reviewer says that the services are medically necessary. Our physician reviewer found the request 
for a PET/CT is reasonable since the past PET/CT scans have proven useful in documenting tumor recurrence. 
As the last scan was negative it is reasonable to re-assess 6 months later to determine if metastatic disease has 
recurred. PET/CT has proven to be the most sensitive means to do so for this particular 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 a PET CT scan from skull base to mid-thigh have been met. Therefore, we 
decided that the Plan has to pre-approve a positron emission tomography (PET) computed tomography (CT) 
scan from skull base to mid-thigh (78815).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 73590 provided on February 26, 
2020. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 73590 is radiologic examination; tibia and fibula, 2 
views. 
 
We find that CPT code 73590 is not supported in the medical record. Specifically, the diagnosis code(s) 
associated to the code are mismatched to the procedure modifier on the claim line. Based on this information, 
we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided 
that the Plan does not have to pay for the x-ray services coded 73590 provided on February 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110), speech/hearing therapy 
(92507), neuromuscular reeducation (97112), language comprehension (92523), physical therapy evaluation; 
high complexity  (97163) and physical therapy; low complexity (97161) provided on August 19, 2019 to 
August 22, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the therapeutic exercises, speech/hearing therapy, neuromuscular reeducation, 
language comprehension, physical therapy evaluation; high complexity and physical therapy; low complexity. 
You say that the services rendered were medically necessary. The Plan denied your request. The Plan says prior 
authorization must be obtained for services provided by an out-of-network provider. 
 
The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must 
furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment. 
 
The requested provider in this case is not a network provider with the Plan. We looked at the file and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot 
review to see if the services were urgent/emergent or medically necessary.  Therefore, we decided that the Plan 
does not have to pay for the therapeutic exercises (97110), speech/hearing therapy (92507), neuromuscular 
reeducation (97112), language comprehension (92523), physical therapy evaluation; high complexity  (97163) 
and physical therapy; low complexity (97161) provided on August 19, 2019 to August 22, 2019 by an out of 
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) (E1399) provided on 
March 5, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for DME. You say that you believe you should be reimbursed for the claim because 
you were told the item was covered. The Plan denied your request. The Plan says prior authorization must be 
obtained for out-of-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) (E1399) 
provided on March 5, 2020 by an out of network (OON) provider.
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. You say that the enrollee attempted to take oral alendendorate and 
had to discontinue treatment due to muscle and joint pain. You say that the enrollee received the drug under the 
care of a different provider and plan thus their current plan has no record of this. You also say that zoledronic 
acid is in the same family as alendendorate and therefore the enrollee would have the same side effects. The 
Plan denied your request. The Plan says the requested drug is not on the list of preferred drugs. The Plan also 
says the provided documentation does not show that you have tired or cannot use zoledronic acid. 
 
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 the 
service is not medically necessary. Our physician reviewer found the provided documentation does not support 
 
 
a history if an osteoporotic fracture or previous treatment, contraindication, or intolerance to zoledronic acid. 
The reviewer found that step therapy, as outlined by the plan, requires this documentation.  The reviewer fond 
that without the support of the documentation, Prolia is not approved as step criteria is not met. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRuxience for the enrollee.You asked the Plan to pre-approvethe drug. You say that this is medically necessary.The Plan denied your request. The Plan says the criteria is not met for an off-label indication.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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found theenrollee has a diagnosis of bullous pemphigoid confirmed by biopsy. The review of Medicare approved compendia does not support the use of Ruxience for the treatment of this condition. Without the support of the documentation, Medical necessity cannot be determined.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 drug have not been met.Therefore, we decided that the Plan does not have to pre-approveRuxience for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe AndroGel, 1% gel packet.You asked the Plan to pre-approvethe AndroGel. You say that the enrollee has been on this medication since 2010. You also say that the enrollee is stable on this medication.The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is 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 pre-approvethe AndroGel, 1% gel packet.Benefits for the AndroGelmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of 
SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the continuation of SNF care. 
 
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 the continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 
require ongoing skilled nursing services with the specialized skill, knowledge and judgment of a skilled 
professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a 
SNF beyond the last covered date.  The enrollee does not have complex wound care or other ongoing SNF 
level SN need. The enrollee's functional level does not require ongoing skilled therapy services with the 
 specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically 
necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy 
services (or a combination of these services) on a daily basis in a SNF. As a practical matter, this enrollee does 
not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last 
covered date. 
 
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 continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
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 enrollee needs continued medical management, 
and aggressive therapy for significant functional deficits. The Plan denied your request. The Plan says the 
enrollee does not require physician supervision, or a multidisciplinary team for 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 physician reviewer found 
that the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not 
shown to be able to perform fifteen hours per week of rehabilitative 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 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dextroamp-Amphetamin. 
 
You asked the Plan to pre-approve Dextroamp-Amphetamin. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 Dextroamp-Amphetamin.  
 
Benefits for Dextroamp-Amphetamin 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that you are appealing. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because the records do not 
show that the enrollee has a specific diagnostic indication for which spinal cord stimulator may be covered. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered for the 
indications listed 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 spinal cord stimulator. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested spinal cord stimulator trial. Our 
physician reviewer found the enrollee does not have a covered indication for a spinal cord stimulator, therefore 
this request is not medically reasonable or 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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pennsaid. 
 
You asked the Plan to pre-approve Pennsaid. The Plan denied your request. The Plan says this drug is not 
covered under the enrollee's Part B plan. 
 
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 Pennsaid.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found IRF admission is not medically necessary for this enrollee, and also does not meet the CMS coverage criteria. Her rehab needs can be safely and effectively met in an alternate, less intense setting such as in an SNF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis, 0.05%. 
 
You asked the Plan to pre-approve Restasis. You say that the enrollee has trialed multiple over the counter eye 
drops. You also say that they did not provide the relief that is needed. The Plan denied your request. The Plan 
says the requested drug is considered self-administered. The Plan says self-administered drugs are covered 
under a Medicare Part D prescription drug plan. The Plan says the requested drug is 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 pre-approve Restasis, 0.05%.