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

 
We decided that the Plan has to pay for skin substitute graft services (CPT 15273) provided to the enrollee on 
November 11, 2019. 
 
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 that procedure code 15273 is not supported by the medical records submitted. 
 
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 15273 is "application of a skin substitute graft to the trunk, arms or legs, on a total wound surface area 
greater than or equal to 100 sq cm, for the first 100 sq cm wound surface area, or 1% of body area of infants 
and children 
 
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 services. Our reviewers says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found CPT 
15273 is supported and substantiated in the medical records and operative report. The code is supported in the 
description of the 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 the services have been met. Therefore, we decided that the Plan has to pay for 
skin substitute graft services (CPT 15273) provided to the enrollee on November 11, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87150, 87481, 87491, 87500, 87529, 
87591, 87640, 87641, 87651, 87653, 87661, 87798, 87801) provided on March 30, 2020. 
 
You asked the Plan to pay for laboratory services. You say that these services are supported in the records. The 
Plan denied your request. The Plan says these services do not have a qualifying originating site. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
 
 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for laboratory services (87150, 
87481, 87491, 87500, 87529, 87591, 87640, 87641, 87651, 87653, 87661, 87798, 87801) provided on March 
30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 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 Keytruda. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found you have metastatic nsclc, PDL1 negative. Per compendia and literature first line keytruda for 
metastatic nsclc requires PDL1+ disease. The documentation shows that you are PDL1 negative. Therefore, 
you do not meet criteria for the requested drug.
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not tried sufficient conservative treatment. 
 
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 Gelsyn-3. Our reviewer says that the 
criteria for coverage of Gelsyn-3 has not been met. Our physician reviewer found here is no documentation of 
adequate conservative measures for knee pain including a 6-week trial and failure of physical therapy. Gelsen-3 
is not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for denosumab (a Medicare Part B drug) and 
infusion administration service provided on July 14, 2020. 
 
You asked the Plan to waive the cost-sharing for Part B drug and infusion administration service. You say that 
you cannot afford this amount each month. The Plan denied your request. The Plan says the cost-sharing 
amounts you are being charged are 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 20% 
coinsurance for in-network Part B drugs and $325 for in-network administration services at an outpatient 
hospital. The allowed amount of the drugs is $2,388.12, resulting in a coinsurance amount of $477.62. For the 
administration services, you have been asked to pay the allowed amount of $73.26, because this amount is less 
than the $325 copayment for administration services in an outpatient hospital. Your total cost-sharing 
obligation is therefore $550.88. 
 
You have been asked to pay 20% coinsurance for Part B drugs and less than $325 for administration services. 
Part B drug and infusion administration service fall within the "Medicare Part B Prescription Drugs" and 
"Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers" benefit categories. 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 cost-sharing for denosumab (a 
Medicare Part B drug) and infusion administration service provided on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a set of dentures (D5110, D5120). 
 
You asked the Plan to pre-approve a set of dentures. You say that your previous dentures broke completely. 
The Plan denied your request. The Plan says rules for pre-approval for a set of dentures have not been met. 
 
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. The Plan covers a set of 
dentures every five years.  
 
We looked at the case file and Medicare rules. You have previously obtained a set of dentures in January 2020. 
Your benefit is exhausted for 2020. Based on this information, we decided that the Plan's rules for coverage of 
a set of dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve a set of 
dentures (D5110, D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ASL single switch scanner (K0108) and attendant 
control (E2331) for an approved power wheelchair (PWC). 
 
You asked the Plan to pre-approve the switch scanner and attendant control. You say that all requested items 
should be approved as medically necessary. The Plan denied your request. The Plan says all items are approved 
aside from the attendant control and the single switch scanner. 
 
The Plan must follow Medicare rules. Medicare rules say that an attendant control is not covered when 
provided along with a beneficiary-operated drive control. In addition, the function of a single switch control is 
included in the drive control already approved for this wheelchair. Therefore, we decided that the Plan does not 
have to pre-approve the ASL single switch scanner (K0108) and attendant control (E2331) for an approved 
power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MBBs are covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has complaints of back 
pain. There is no documented current clinical assessment of the type and location of pain. There is no 
documented current clinical assessment to implicate the facet joint as the putative source of this enrollee's pain. 
The most recent physical exam in the submitted documentation was in 2014. The records do not support that 
the criteria for coverage of the requested MBBs are met; therefore, the services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve medial branch blocks (MBBs).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental core build-up (D2954). 
 
You asked the Plan to pre-approve core build-up. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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, the requested items or services are not 
among those covered under this benefit. Specifically, the service is not listed in the Plan's benefit handbook. 
Therefore, we decided that the Plan does not have to pre-approve dental core build-up (D2954).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental healthcare provided on 
August 10, 2020. 
 
You asked the Plan to waive the copayment for outpatient mental healthcare. You say that you feel that the 
copayment should be waived because it should be considered a specialist visit. 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 $40 
copayment for outpatient mental healthcare.  
 
You have been asked to pay a $40 copayment for outpatient mental healthcare. Outpatient mental healthcare 
falls within the outpatient mental healthcare 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 outpatient mental healthcare provided on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute. 
 
You asked the Plan to pre-approve these services. You say that you need the scooter to assist in mobility after 
surgery. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a crutch substitute is denied as not medically 
necessary. 
 
We looked at the file and Medicare rules. The services at issue are a crutch substitute described by procedure 
code E0118. These services are denied by Medicare as not medically necessary. Therefore, we decided that the 
Plan does not have to pre-approve a crutch substitute.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says research has not found this procedure to be helpful. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the 
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the MILD procedure remains experimental for the treatment of spinal stenosis. More research is needed 
to show safety and efficacy. The gold standard procedure is open laminotomy decompression surgery. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous laminotomy/laminectomy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that ESIs are covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic neck and low 
back pain. She has diagnoses of spinal stenosis and lumbar radiculopathy. The physical exam does not 
document which spinal levels are affected and there is no documentation of tests, such as straight leg raising. 
There are no imaging reports submitted for review. The records do not support that the ESI is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network and an out-of-area 
provider for a colonoscopy. 
 
You asked the Plan to pre-approve the referral. You say that this is needed to be done near the enrollee's sister 
due to the requirement of sedation. 
 The Plan denied your request. The Plan says this is not medically necessary or urgent to be done out of area. 
 
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 to an out-of-network and an out-of-area provider for a colonoscopy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vascepa 1 GM Capsule. 
 
You asked the Plan to pre-approve Vascepa. 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 Vascepa 1 GM Capsule.  
 
Benefits for Vascepa 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services that you provided on August 14, 2019. 
 
You asked the Plan to pay for the physician's services. 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 
member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services that you provided on August 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on August 19, 
2020 out of network.  
 
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 the enrollee did not have prior authorization for out of network care. 
 
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 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 medical services provided 
to the enrollee on August 19, 2020 out of network.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for Optomap provided on August 26, 2020. 
 
You asked the Plan to pay for the Optomap. The Plan denied your request. The Plan says that this service is not 
covered by the Plan. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the Optomap by a contract provider. The file does not show that the Plan provided notice 
that the Optomap would not be covered prior to the services being provided. Under Medicare rules, this means 
the Optomap is considered approved by the Plan. Therefore, we decided that the Plan has to pay for Optomap 
provided on August 26, 2020.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sleep study (95811) provided on May 15, 2020. 
 
You asked the Plan to pay for the sleep study. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 95811 is not supported in the medical record. Specifically, the documentation does not 
show a qualifying evaluation and management visit within the past year prior to the sleep study performed. For 
all diagnostic tests, including polysomnography, CMS requires an order from the provider who evaluates or 
treats the enrollee. Based on this information, we decided that Medicare rules for coverage of the sleep study 
have not been met. Therefore, we decided that the Plan does not have to pay for the sleep study (95811) 
provided on May 15, 2020.