Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an extracapsular cataract removal with 
insertion of intraocular lens prosthesis procedure (66984) provided on March 16, 2021. 
 
You asked the Plan to waive the copayment for an extracapsular cataract removal procedure. You say that you 
feel like you should not have to pay for this visit based on how you were treated. The Plan denied your request. 
The Plan says the copayment you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment per visit, for exams to diagnose and treat diseases and conditions of the eye. Your contract with the 
Plan also says that enrollees must pay a $40 copayment per visit for a specialist outpatient hospital service. You have been asked to pay a $30 copayment for an extracapsular cataract removal procedure. The EOC 
confirms that you pay a $30 copayment for exams to diagnose and treat diseases and conditions of the eye 
under your vision care benefit. The EOC also confirms that you pay a $40 copayment for a specialist outpatient 
service. The records show that the Plan asked you pay a $30 copayment which is lower than the specialist 
outpatient procedure copayment of $40. 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 an 
extracapsular cataract removal with insertion of intraocular lens prosthesis procedure (66984) provided on 
March 16, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing rendered on October 19, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has metastatic poorly-
differentiated carcinoma with neuroendocrine differentiation. She was recently diagnosed with small cell lung 
cancer on the left. The documentation does not support that tissue-based comprehensive genomic profiling 
(CGP) is infeasible (i.e., quantity not sufficient for tissue-based CGP or invasive biopsy is medically 
contraindicated) for this enrollee. The services were 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 pay for the Guardant360 testing rendered on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and debridement provided on September 2, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and debridement. You say that the service was medically 
necessary due to the severity of the infection. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit and debridement provided on September 2, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
June 30, 2021, to July 10, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you are a senior with 
limited income. The Plan denied your request. The Plan says you were charged the correct cost sharing 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 $195 
copayment per day for days 1 to 6 for in-network, inpatient hospital care.  
 
 
 
 
 
 
 
 You have been asked to pay a $195 copayment per day for days 1 to 6 for inpatient hospital services, which is a 
total of $1,170 ($195 x 6 = $1,170). Inpatient hospital services fall within inpatient hospital 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 inpatient hospital services provided from June 
30, 2021, to July 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you appear to be more stable but have a poor neurological prognosis and require only 
short-term additional acute care hospital services that can safely completed at the current facility. You do not 
require services at the LTACH that are not already available at the current facility. Transfer to LTACH is not 
medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be 
considered when treatment has completed. 
 
 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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided from August 10, 2021, through 
August 14, 2021, and billed with principal diagnosis code A41.51 and secondary diagnosis code G92. 
 
You asked the Plan to pay for the inpatient hospital care as billed. You say that the inpatient hospital care was 
billed correctly. The Plan denied your request. The Plan says that the documentation that has been provided 
supports a differing diagnosis than what was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with the principal diagnosis code, A41.51, defined as 
sepsis due to Escherichia coli and the secondary diagnosis code, G92, defined as toxic encephalopathy. 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 inpatient hospital care as billed. Our 
reviewer says that the documentation supports the billing of principal diagnosis code A41.51 and secondary 
diagnosis code G92. Our physician reviewer found that the enrollee was a then 74-year-old woman who 
presented to the hospital on August 10, 2021, with fever and altered mental status. Vital signs were notable for 
fever, hypotension, and tachycardia. The enrollee was ill-appearing and disoriented. Laboratory studies were 
notable for marked leukocytosis. Urinalysis suggested an infection in the urinary tract. Blood culture showed 
growth of gram negative rods. Intravenous antibiotics were administered. The enrollee's white blood cell count 
returned to normal. The plan suggests that N12 (Tubulo-interstitial nephritis) is more appropriate. However, the 
documentation supports the use of principal diagnosis code A41.51 and secondary diagnosis code G92 in this 
case. The documentation supports the inpatient care as billed with the original DRG, not the Plans change to 
the DRG. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the inpatient hospital care provided from August 10, 2021, 
through August 14, 2021, and billed with principal diagnosis code A41.51 and secondary diagnosis code G92.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection processing and storage of autologous blood 
(86891), washed white blood cells (P9022) and special pump services (99190 and 99191) provided on June 29, 
2021. 
 You asked the Plan to pay for the collection processing and storage of autologous blood, washed white blood 
cells and special pump services. You say that you would like reconsideration based on the records submitted. 
The Plan denied your request. The Plan says payment for these services is included in the payment to the 
facility. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the collection processing and storage of autologous blood, washed white blood cells and special 
pump services have not been met. Specifically, the record indicates that the member was registered inpatient on 
the billed date of service. Payment for these services is included in the payment to the facility and is the 
responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the 
collection processing and storage of autologous blood (86891), washed white blood cells (P9022) and special 
pump services (99190 and 99191) provided on June 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vraylar 3mg capsules. 
 
You asked the Plan to pre-approve Vraylar capsules. The Plan denied your request. The Plan says Vraylar is a 
self-administered drug and does not fall under Part B coverage. 
 
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 Vraylar 3mg capsules.  
 
 
 
 
 
  
Benefits for Vraylar capsules 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 pay for biopsy of tongue (41105) deep sedation/general anesthesia, 
initial 15 minutes (D9222) provided August 5, 2021. 
 
You asked the Plan to pay for the outpatient procedure. You say that you were told by the Plan that the codes 
would be covered if you sent them in, even though the doctor opted out of Medicare. You followed everything 
you were told to do. The Plan denied your request. The Plan says if you go to a provider who is not eligible to 
participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for biopsy of 
tongue (41105) deep sedation/general anesthesia, initial 15 minutes (D9222) provided August 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you live alone and take care of yourself. After the 
fall you have been a little weak but with the IRF program you will be able to return home back to your normal 
life. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 you do not require the intensity of services provided at an IRF. Your care needs can be met at a lower level of 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (99203, 72040, 98940) provided on 
January 14, 2021, to February 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that you had previously appealed another 
member's services, and the Plan overturned the denial and paid you stating that because you are out of network, 
claims should have, in fact been paid by the Plan. The Plan denied your request. The Plan says the services 
under appeal were rendered by a provider who is not under contract with the Plan or in the Plan's service area. 
The Plan also states that the claims were denied as not authorized, and the member was self-referred. 
 
 
 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 had network providers 
available who could have provided 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 chiropractic services (99203, 72040, 98940) 
provided on January 14, 2021, to February 8, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a regimen of Neulasta, cyclophosphamide, doxorubicin, 
vincristine, and ondansetron. 
 
You asked the Plan to pre-approve Neulasta, cyclophosphamide, doxorubicin, vincristine, and ondansetron. 
You say that the enrollee has exhausted all other options and needs these injections. The Plan denied your 
request. The Plan says the denial of authorization for this drug regimen is correct, because this is not medically 
necessary and not supported by drug compendia or medical literature. 
 
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 Neulasta, cyclophosphamide, 
doxorubicin, vincristine, and ondansetron. Our reviewer says that the enrollee does not meet the Medicare 
criteria for the requested drug regimen. Our physician reviewer found the regimen of Neulasta, 
cyclophosphamide, doxorubicin, vincristine, and ondansetron is not Food & Drug Administration (FDA) 
approved for the enrollee's diagnosis. This regimen is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta, cyclophosphamide, doxorubicin, vincristine, and ondansetron have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a regimen of Neulasta, 
cyclophosphamide, doxorubicin, vincristine, and ondansetron.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycontin. 
 
You asked the Plan to pre-approve Oxycontin. You say that the drug in dispute is medically necessary and 
supported by the records provided. The Plan denied your request. The Plan says the requested drug does not 
fall under Part B coverage. The Plan says that the enrollee does not have pharmacy benefits administered 
through them. 
 
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 Oxycontin.  
 Benefits for Oxycontin 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator. 
 
You asked the Plan to pre-approve the stimulator. You say that this device stimulates the bone growth after 
surgery. The Plan denied your request. The Plan says this request is unable to be approved. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
 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 stimulator. Our reviewer says that 
the requested stimulator is not medically reasonable or necessary. Our physician reviewer found there is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the noted pathology. The proposed procedure is at one lumbar level. Detailed documentation is 
not evident regarding significant risk factors for failed fusion or that the previous fusion at adjacent level had 
failed to fuse. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the request for electric bone growth stimulator 
(osteogenesis stimulator (E0748) 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 the stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an osteogenesis stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room visit (99285), the oral 
prescription drugs (J8499 x 3), the radiographic procedure (76499), and the office visit (99213) provided from 
March 26, 2021, through March 30, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $90 
copayment for Medicare-covered emergency room visits and urgently needed services received outside the 
United States or United States territories.   
You have been asked to pay $217.40 ($90+ $37.40 +$90) for the services performed in an urgent care facility 
out of the county on March 26, 2021, March 29, 2021, and March 30, 2021. This amount is less than the total 
applicable copayments for these services. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the 
emergency room visit (99285), the oral prescription drugs (J8499 x 3), the radiographic procedure (76499), and 
the office visit (99213) provided from March 26, 2021, through March 30, 2021.