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

We decided that the Plan does not have to waive the coinsurance for the bevacizumab injection provided on 
June 3, 2020, July 13, 2020 and August 10, 2020. 
 
You asked the Plan to waive the coinsurance for the bevacizumab injections. You say that you were approved 
for the injections. You say that $30 should be removed from each visit. The Plan denied your request. The Plan 
says the coinsurance applied 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 20% 
coinsurance for chemotherapy drugs and all other drugs covered under Medicare Part B. 
 
You have been asked to pay $100, which is 20% of the allowed amount for each bevacizumab injection. The 
allowed amount is $500 (20% x $500 = $100). The total amount you owe is $300 ($100/injection x 3 injections 
= $300). The bevacizumab injections fall within the "Medicare Part B prescription drugs" 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 coinsurance for the bevacizumab injection provided on June 3, 2020, July 
13, 2020 and August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Phlebectomy (treatment of varicose veins). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the records provided indicate that no other procedure is planned. 
 
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 services. Our physician reviewer 
found the documentation does not support the medical necessity of the procedure in question. It is not possible 
to attribute the patient's leg pain, particularly in a patient with a history of atrial fibrillation and a 
hypercoagulable state, to varicose veins without assessment of arterial perfusion. There is insufficient 
documentation that the patient is having lifestyle limiting symptoms and insufficient documentation that there 
has been an effort at conservative treatment. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve Phlebectomy (treatment of varicose veins).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve in-home nursing care services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
services are not valid for Medicare purposes. 
 
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 S9123 is nursing care, in the home; by registered nurse, 
per hour. The CPT Code Manual definition of code S9124 is nursing care, in the home; by licensed practical 
nurse, per hour.  
 
We find that CPT code S9123 and S9124 are not valid for Medicare purposes. Medicare uses another code for 
the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve in-home nursing 
care services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on April 8, 2020. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration 
because the member was seen by different providers from different groups. The Plan denied your request. The 
Plan says per a review of claims summary for this patient, CPT code 99233 was processed and paid for the 
billed date of service. 
 
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 code 99232 is not supported in the record. Specifically, the record indicates that two 
evaluation and management services were rendered by providers in the same group with the same specialty on 
the billed date of service. Based on this information, we decided that Medicare rules for coverage of the 
subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for 
subsequent hospital care (99232) provided on April 8, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography of the neck and soft tissue. 
 
You asked the Plan to pre-approve computed tomography of the neck and soft tissue. You say that there is a 
concern for recurrent cancer. The Plan denied your request. The Plan says that the CT scan is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 computed tomography of the neck and 
soft tissue. Our reviewer says that the service is medically necessary. Our physician reviewer found NCCN 
guidelines B cell lymphoma, page NGMLT-3, allows re-imaging with modality used previously for follow-up. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computed tomography of the neck and soft tissue have been met. Therefore, we 
decided that the Plan has to pre-approve computed tomography of the neck and soft tissue.  
 
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: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve ambulance services for the enrollee. 
 
You asked the Plan to pre-approve ambulance services. You say that the enrollee requires this transport to get 
to dialysis. The Plan denied your request. The Plan says that that medical necessity criteria has not been met. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient?s health. The Plan follows the same rules.  
 
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 ambulance services. Our reviewer says 
that ambulance services are medically reasonable and necessary for the enrollee in this case. In this instance 
there are no other options for transportation for dialysis with the exposure to Covid. Our physician reviewer 
found that the enrollee's condition meets criteria for coverage of ambulance 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 ambulance services have been met. Therefore, we decided that the Plan has to 
pre-approve ambulance services for the enrollee.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and cleaning 
(D1110). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has an upcoming appointment. 
You also say that the enrollee has not had a cleaning in a while. The Plan denied your request. The Plan says 
dental services that you receive out of network are not covered. The Plan also says there are dental providers in 
network with the Dental Plan that are available to provide these services. 
 
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. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150) and cleaning (D1110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have  knee orthosis (L1833) and suspension sleeve (L2397 lumbar sacral 
orthosis (L0650) provided July 17, 2020 
 
You asked the Plan  the orthoses. You say that the enrollee had an in person consultation with their physician 
as noted on their medical records. The enrollee has tried rest, exercise and medication according to the doctor's 
notes. The Plan denied your request. The Plan says the medical records do not support the medical necessity of 
the orthoses. 
 
 
 
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 the orthoses. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the available documentation in the case file does not support that the requested lumbar-sacral orthosis 
was medically reasonable and necessary for the enrollee in this case. A physical examination of the back would 
reasonably be required to adequately assess whether the coverage criteria for a lumbar sacral orthosis have been 
met. The documentation does not support that the lumbar-sacral orthosis is being prescribed for one or more of 
the covered indications in this case, as there is no documentation of a physical examination of the back. 
the documentation in the case file does not support that the requested knee orthosis and sleeve were medically 
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the 
LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's 
knees, and there is no credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not 
separately payable when the base item is not covered. 
 
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 orthoses have not been met. Therefore, we decided that the Plan does not 
have  knee orthosis (L1833) and suspension sleeve (L2397 lumbar sacral orthosis (L0650) provided July 17, 
2020
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that they did not receive documentation regarding step therapy criteria. 
 
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 Prolia is 
not medically reasonable and necessary for the enrollee. The patient has not tried and failed zoledronic acid or 
that the enrollee has a history of osteoporotic fracture. There is no documentation provided indicating that the 
Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Our 
physician reviewer found that the enrollee's condition does not meet step therapy criteria for Prolia. 
 
 
 
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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires daily doctor visits, 
respiratory therapy, and nursing monitoring. The Plan denied your request. The Plan says the enrollee no longer 
requires hospital level of care or special nursing care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical 
services that are materially different than those of short term acute care hospitals. In this case, ongoing care 
needs include oxygen supplementation, intermittent BiPAP, surveillance laboratory studies, intermittent 
dialysis as indicated, and therapy services. The documentation does not support that the enrollee in this case 
requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. There are no required medical services identified that are available at the LTACH, that are not available at 
the current health care setting being offered by the health plan. Consequently, the requested LTACH services 
are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Toviaz Tablet. 
 
You asked the Plan to pre-approve Toviaz Tablet. 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 Toviaz Tablet.  
 
Benefits for Toviaz Tablet 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has spinal stenosis. The 
requested Superion spacer is considered experimental in nature, as more research is needed to show safety and 
efficacy. The services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopy (55866) and release of ureter (50940). 
 
You asked the Plan to pre-approve laparoscopy and release of ureter. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 laparoscopy and release of ureter. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the available clinical documentation at this time does not support that 
Enterolysis and Release of Ureter is medically reasonable and necessary for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laparoscopy and release of ureter have not been met. Therefore, we decided that 
the Plan does not have to pre-approve laparoscopy (55866) and release of ureter (50940).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve jaw surgery. 
 
You asked the Plan to pre-approve jaw surgery. You say that the services are necessary. The Plan denied your 
request. The Plan says routine dental care is not a covered benefit of Medicare. The Plan states the member's 
plan has a supplemental benefit for dental care that goes beyond what original Medicare covers; however, this 
supplemental benefit does not include coverage of the appealed bone grafts and related procedures. 
 
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. The services are not listed in your EOC as a covered benefit; therefore, the services are not 
covered. Therefore, we decided that the Plan does not have to pre-approve jaw surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an out of network flu shot provided on September 28, 2020. 
 
You asked the Plan to pay for this service. You say that this shot should be covered by the Plan. The Plan 
denied your request. The Plan says immunizations are not covered out of network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 an out of network flu shot provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99214, 99204) to be provided 
by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient office visit. You say that you have previously seen this 
provider and you would like to continue to see this provider. The Plan denied your request. The Plan says 
enrollee's must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 
the outpatient office visit (99214, 99204) to be provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on June 11, 2020. 
 
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 should be submitted to Original Medicare. 
 
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 dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician services provided to the enrollee on June 11, 2020.