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

 
We decided that the Plan does not have to pre-approve testosterone cypionate (J1071). 
 
You asked the Plan to pre-approve testosterone cypionate. You say that you have been taking this medication 
since 2013. The Plan denied your request. The Plan says coverage of this medication is the responsibility of 
your prescription drug 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 testosterone cypionate 
(J1071).  
 
Benefits for testosterone cypionate 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need physical therapy for your right leg. The 
Plan denied your request. The Plan says that your request does not show it would cause excessive physical 
hardship for you to receive needed care in an outpatient basis or skilled nursing facility. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your medical status currently does not require 
intensive physician and nursing supervision in an IRF. While you may benefit from additional physical and 
occupational therapy the documentation does not support that you can fully tolerate this therapy on an intensive 
level in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the electrocardiogram (93010) provided on June 2, 2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that there is no documentation of an 
interpretation by the rendering provider. 
 
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 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 electrocardiogram. Our reviewer says 
that this provider's reading of the electrocardiogram is separately billable as a formal interpretation and report. 
Our physician reviewer found there is no evidence that this provider saw the member in the emergency 
department. 
 
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 electrocardiogram have been met. Therefore, we decided that the Plan has to 
pay for the electrocardiogram (93010) provided on June 2, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan (78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan 
denied your request. The Plan says that a PET scan is not medically necessary at this time. 
 
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 the PET scan. Our reviewer says that 
the requested PET scan is medically necessary. Our physician reviewer found the enrollee has advanced head 
and neck cancer and had an initial PET scan in August 2020. The additional PET scan is medically appropriate 
based on guidelines. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a Positron Emission Tomography (PET) scan (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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem-focused oral exam, intraoral x-rays, crown with 
post and core, and root canal you received. 
 
You asked the Plan to pay for the dental services. 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 Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. 
The requested services are not listed, and therefore are not covered. Therefore, we decided that the Plan does 
not have to pay for the problem-focused oral exam, intraoral x-rays, crown with post and core, and root canal 
you received.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on June 30, 
2020. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says since the enrollee was enrolled in 
hospice care you need to bill Original Medicare for the services rendered. 
 
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 the subsequent hospital care (99232) provided on June 30, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services with CPT code J1642 provided on June 
26, 2020 and June 27, 2020. 
 
You asked the Plan to pay for CPT code J1642. 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 looked at the file and Medicare rules. CPT code J1642 has a status indicator of "E" under the Medicare 
Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for these codes under the fee 
schedule as payment for these codes are excluded from the physician fee schedule by regulation. Therefore, we 
decided that the Plan does not have to pay for the injection services with CPT code J1642 provided on June 26, 
2020 and June 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of a lower extremity joint (73721). 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because this service 
is medically necessary. The Plan denied your request. The Plan says there is no documentation that the member 
had a course of physical therapy and no x-rays have been obtained 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that current 
evidence based medical guidelines and literature would not support this request prior to documented failure of 
a comprehensive conservative treatment trial, with physical therapy and exercise, and radiographs. There is no 
detailed history of trauma. There is no clear documentation of functional limitations. Our physician reviewer 
found this request for MRI of the lower extremity would not be considered medically reasonable and 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of a lower extremity joint (73721).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6535. 
 
You asked the Plan to pre-approve the compression stockings. You say that these are needed to prevent the 
enrollee from getting stasis ulcerations. The Plan denied your request. The Plan says that these are not covered 
by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6535 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6535.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950). 
 
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. Covered services are listed in 
the Plan?s dental customer handbook. 
 
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 requested is not listed in the Plan?s EOC or 
dental customer handbook, and therefore, is not a covered service. Therefore, we decided that the Plan does not 
have to pre-approve core build up (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hero pill dispenser. 
 
You asked the Plan to pre-approve the requested item. You say that the enrollee needs the dispenser for 
medication. The Plan denied your request. The Plan says the dispenser is excluded from Medicare coverage. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Hero pill dispenser.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for speech therapy services provided from 
February 21, 2020, through August 12, 2020. 
 
You asked the Plan to waive the copayment for speech therapy services. You say that you asked to have 
therapy on the same days, so you didn't get charged twice. The Plan denied your request. The Plan says the 
copayments 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 $35 per 
day for Medicare-covered speech language therapy services from an in-network provider.  
 
You have been asked to pay a $35 copayment for each speech therapy visit. Speech therapy services fall within 
the "Outpatient rehabilitation 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 speech therapy services provided from February 21, 2020, through August 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 17, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on June 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the unna boot strapping provided. 
 
You asked the Plan to waive the copayment for the unna boot strapping. You say that these dates did not 
involve surgery nor a follow-up to any surgical procedure. You say that this is a coding error because each visit 
was for wound care. The Plan denied your request. The Plan says the copayments 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 a $275 
copayment for each in-network, Medicare-covered outpatient hospital facility visit. 
 
You have been asked to pay $203.22 for each visit for unna boot strapping. The total amount you owe is 
$3,048.30 ($203.22/visit x 15 visits = $3,048.30). The unna boot strapping falls within the "Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. 
The unna boot strapping is considered a surgical service. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the unna boot strapping provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the manual wheelchair purchased on July 17, 2020 
from an out of network provider. 
 
You asked the Plan to reimburse you for the manual wheelchair. You say that you purchased a wheelchair 
because you could not walk into a store. The Plan denied your request. The Plan says they have in-network 
providers who could have provided a wheelchair. 
 
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 reimburse you 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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We 
found no exception that would require the Plan to reimburse you for this item. Therefore, we decided that the 
Plan does not have to reimburse you for the manual wheelchair purchased on July 17, 2020 from an out of 
network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on July 3, 2020. 
 
You asked the Plan to pay for the testing. You say that you would like reconsideration because this testing 
should be covered. The Plan denied your request. The Plan says this testing requires prior authorization and the 
provider was out of network at the time of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, this service was not billed correctly. Per Medicare, 
Guardant360 testing should be billed with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for Guardant360 testing provided on July 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation - per quadrant (D4921). 
 
You asked the Plan to pre-approve gingival irrigation - per quadrant. 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. 
 
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 
gingival irrigation - per quadrant (D4921).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 day sensor. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested 
items. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and related supplies are 
considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing 
at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment 
of insulin dosage based on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 14 day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14 day sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency neurolysis for 
the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this service is limited to two sessions in any rolling 12-month year. 
 
The Plan must follow Medicare rules. Medicare rules say that two radiofrequency ablation sessions are allowed 
per rolling 12-month year. 
 
The records show previous sessions in April and May 2020. The enrollee would not be eligible for the 
requested service until April 2021. 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 lumbar/sacral 
facet joint radiofrequency neurolysis for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D4265). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under the enrollee's 
contractual policy. 
 
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 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve biologic 
materials to aid in soft and osseous tissue regeneration (D4265).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda 200 mg (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that these services are medically necessary to treat the 
enrollee's condition. The Plan denied your request. The Plan says the use of Keytruda is not medically accepted 
for the enrollee's condition. 
 
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 
service is not medically necessary. Our physician reviewer found the use of Keytruda to treat the enrollee's 
medical condition is not indicated, not recommended or not supported in any of the Medicare-approved 
compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda 200 mg (J9271).