Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has plaque psoriasis. He 
has not tried and failed the Plan's required drug, Stelara. The records do not show that the required drug would 
be contraindicated or less effective; therefore, Ilumya is 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 Ilumya.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. He 
has not tried and failed the Plan's required drugs, Durolane, Monovisc, or Synvisc-One. The records do not 
show that the required drugs would be contraindicated or less effective; therefore, Gel-One is 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 Gel-One.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Tecentriq. 
 
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 that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has stage IIA unresected non-
small cell lung cancer (NSCLC). Tecentriq is Food and Drug Administration (FDA)-approved for adjuvant 
treatment (as a single agent) following resection and platinum-based chemotherapy in adults with stage II to 
IIIA NSCLC whose tumors have PD-L1 expression on greater than or equal to one percent of tumor cells, as 
determined by an approved test. The enrollee's tumor is PD-L1 95 percent and he has completed platinum-
based chemotherapy. Poor performance status is due to prior chemoradiation and should improve. The service 
is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve Tecentriq.  
 
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 6 additional extractions (D7140, D7210), alveoloplasty 
services (D7310, D7311), and interim complete lower denture (D5811). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot afford to pay for these 
procedures. You say that you are suffering from sinus issues. You say that you think your teeth are causing 
these issues. You also say that your doctors have recommended having your teeth pulled due to infections. The 
Plan denied your request. The Plan says 2 extractions are covered per year. The Plan says that the frequency 
limit has been reached. The Plan says that interim complete lower denture is not listed as a covered service. 
The Plan also says that alveoloplasty services are not listed as covered services either. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 2 extractions are covered per year, 
the frequency limit has been reached. The record shows that the Plan approved 2 extractions on January 20, 
2022, thus reaching the frequency limit. Additionally, the requested interim complete lower denture and 
alveoloplasty services are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve 6 additional extractions (D7140, D7210), alveoloplasty services (D7310, D7311), and 
interim complete lower denture (D5811).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has acinic cell cancer 
diagnosed in 2019 with resection in February of 2021. Per the National Comprehensive Cancer Network 
(NCCN) guidelines, Keytruda is recommended for high tumor mutation burden. It is also Food and Drug 
Administration (FDA)-approved for microsatellite-instability high tumors and deficient MisMatch Repair 
(dMMMR). The enrollee does not meet these criteria. Keytruda is 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 Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic service consultation (D9310), and 
endodontic therapy (D3330) provided by an out-of-network provider. 
 
You asked the Plan to pre-approve a diagnostic service consultation and endodontic therapy. You say that you 
would like the Plan to pay for this. The Plan denied your request. The Plan says services provided by an out-of-
network are 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 Plans coverage rules apply in this case. The Plan covers a diagnostic 
service consultation and endodontic therapy when the services are provided by an out-of-network provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a diagnostic service consultation and endodontic therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a diagnostic service consultation (D9310), and endodontic therapy 
(D3330) provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services (procedure codes 71046, Q0092, and 
R0075) provided on May 18, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were performed in good faith 
and were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not 
covered. 
 
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 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 medical services (procedure codes 71046, Q0092, and R0075) 
provided on May 18, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve Aduhelm (J0172). 
 
You asked the Plan pre-approve Aduhelm. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 pre-approve Aduhelm. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found treatment with Aduhelm should be initiated 
in patients with mild cognitive impairment or mild dementia stage of disease, as this is the population in which 
treatment was initiated in clinical trials. There are no safety or effectiveness data on initiating treatment at 
earlier or later stages of the disease than were studied. 
 
 
 
 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have 
pre-approve Aduhelm (J0172).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
September 22, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. The Plan denied your request. The Plan 
says you have been 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 $45 
copayment for a specialist office visit.  
 
The record shows the provider you saw is a hematology/oncology specialist. You have been asked to pay the 
allowed amount of $17.05, which is less than the $45 copayment for a specialist office visit. A specialist office 
visit falls within the Physician/Practitioner Services, Including Doctors Office Visits 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 a specialist office visit provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on April 15, 2021, through April 27, 2021 and billed with Diagnosis Related Group (DRG) 377 with secondary diagnosis code G93.41.

You asked the Plan to pay for the inpatient hospital services billed with DRG 377. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the DRG 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 G93.41 representing metabolic 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 services billed with DRG 377. Our reviewer says that the documentation does not support DRG 377 with secondary diagnosis code G93.41, metabolic encephalopathy due to inconsistent documentation of the enrollee's mental status and alertness and without a clear and persistent metabolic cause for the symptoms of lethargy beyond her baseline. Our physician reviewer found there was no clear documentation describe the enrollee's baseline. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided on April 15, 2021, through April 27, 2021 and billed with Diagnosis Related Group (DRG) 377 with secondary diagnosis code G93.41.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported crowns (D6065) for teeth # 20, 21, 28 
and 29. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says implant supported crowns are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implant supported 
crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve implant supported crowns (D6065) for teeth # 20, 21, 28 and 29.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the orthotic training. We decided that the Plan does 
not have to waive the copayment for the office visit and injections.  
 You asked the Plan to waive the copayment for the office visit, injections, and training. You say that the cost 
share is wrong. The Plan says that the cost share was applied correctly. 
 
We decided that the Plan has to waive the copayment for the orthotic training (97760).  
 
The Plan follows Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, 
accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 
 
The orthotics training is considered a physician service that would be included in the $5 copay for the office 
visit. Therefore, we decided that the Plan has to waive the copayment for the orthotic training (97760).  
 
We also decided that the Plan does not have to waive the copayment for the office visit and injections. 
 
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 $5 
copay for the office visit, and a 20% coinsurance for the injections. Therefore, we decided that the Plan does 
not have to waive the copayment for the office visit and injections. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for additional ambulance miles provided to the enrollee on 
September 30, 2021. 
 
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 Medicare law contains a restriction that miles beyond the closest available facility cannot be 
billed to Medicare. 
 
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 codes A0425 and A0429 are not supported in the medical record. Specifically, additional 
miles beyond the closest facility are not covered, and should be billed with A0888. 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 pay for additional ambulance miles provided to the enrollee on September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate testing. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the test 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that biomarker testing is only covered under certain 
medical indications. The file shows that exosome prostate intelliscore (EPI) testing was requested. We looked at the file and 
Medicare rules. The records do not show that your prostate specific antigen (PSA) score is less than 10. Based 
on this information, we decided that Medicare rules for coverage of the requested services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve prostate testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an influenza virus vaccine (90662) and for 
the immunization administration (90471) rendered in an urgent care facility on September 10, 2021. 
 
You asked the Plan to waive the copayment for an influenza virus vaccine and for the immunization 
administration rendered in an urgent care facility. You say that you went to a pharmacist to have an influenza 
vaccination, however, the appointment was scheduled through the urgent care in the same facility and now you 
are being charged a $50 copayment because you had this done through the urgent care rather than just the 
straight pharmacy. You also say that there is no reason for this to be listed as an urgent care visit as you only 
needed the vaccination. You also say that you do not feel you should have to pay this copayment as you were 
not aware that the clinic and the pharmacy billed differently. 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 $50 
copayment for Medicare-covered urgently needed care.  
 
You have been asked to pay a $50 copayment an influenza virus vaccine and for the immunization 
administration rendered in an urgent care facility. An influenza virus vaccine and for the immunization 
administration rendered in an urgent care facility falls under the urgently needed 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 an influenza virus vaccine (90662) and for the immunization 
administration (90471) rendered in an urgent care facility on September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (99053) provided on August 9, 2021. 
 
You asked the Plan to pay for code 99053. 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 as billed. 
 
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 looked at the file and Medicare rules. Code 99053 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the medical services (99053) provided on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on September 8, 2021. 
 
You asked the Plan to pay for code 83789. 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 as billed. The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, this claim was billed with the office POS code. The 
records do not support that the member's face-to-face service was rendered in an office setting. Therefore, we 
decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) 
provided on September 8, 2021.