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

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve the drug. You say that you would like this drug to be approved for coverage 
so you do not end up at the hospital again. The Plan denied your request. The Plan says the provider did not 
provide a rationale for use of the non-preferred product for safety or efficacy. 
 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial 
of Ferrlecit, Sodium ferric gluconate, Infed, or Venofer before they will approve the requested drug. In this 
case, you have not tried and failed the required drugs. There is no documentation provided indicating that the 
plans required drugs would likely be less effective and/or likely have adverse effects 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator rental (K0606) rendered 
by the out-of-network (OON) provider on October 27, 2021. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the item was rendered by an out of network provider, 
without prior authorization. 
 
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 had network providers available 
who could have provided 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 pay for this item. Therefore, we decided that the Plan 
does not have to pay for the automatic external defibrillator rental (K0606) rendered by the out-of-network 
(OON) provider on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right lower extremity revascularization. 
 
You asked the Plan to pre-approve right lower extremity revascularization. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have 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 right lower extremity revascularization. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there was no objective severe stenosis noted on imaging to justify the 
right lower extremity revascularization procedure at this time. Also, there was no clear documentation of 
aggressive dietary and medical treatments having failed therapy which is first line for this condition. Therefore, 
the revascularization will be considered 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 right lower extremity revascularization have not been met. Therefore, we 
decided that the Plan does not have to pre-approve right lower extremity revascularization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services (CPT code 95885-26, 95955-26, 
95908-26) provided on August 24, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 95885-26 is needle electromyography, each extremity, 
with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity 
study; limited (List separately in addition to code for primary procedure), 95955-26 is electroencephalogram 
(EEG) during nonintracranial surgery (eg, carotid surgery), and 95908-26 is nerve conduction studies; 3-4. 
 
We find that CPT code(s): 95885-26, 95955-26, and 95908-26, are not supported in the medical record. CPT 
code 95885-26 x2 is not supported by the medical records submitted. The operative report did not include 
documentation of a limited needle electromyography, per each extremity with related paraspinal areas when 
performed, done with nerve conduction, amplitude and latency/velocity study; (listed separately in addition to 
code for primary procedure); therefore, this code cannot be verified. CPT code 95955-26 is not supported by 
the medical records submitted. The operative report did not include documentation of an electroencephalogram 
(EEG) during nonintracranial surgery (carotid surgery); therefore, this code cannot be verified. CPT code 
95908-26 is not supported by the medical records submitted. The operative report did not include 
documentation of a nerve conduction studies for 3-4 studies; therefore, this code cannot be verified. Based on 
this information, we decided that Medicare rules for coverage of the outpatient services have not been met. 
Therefore, we decided that the Plan does not have to pay for the outpatient services (CPT code 95885-26, 
95955-26, 95908-26) provided on August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair options. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The file shows that a power seat elevation system was requested. We looked at the file and the rules. The item 
at issue in this appeal does not serve a purpose that is primarily medical in nature.  
 
The file shows that a charger with mounting kit, and a Logic controller were requested. We looked at the file 
and the rules. These services are not separately payable.  
 
The file shows that an expandable control system was requested. 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 
requested system. Our physician says that the enrollee has a neurologic disorder with functional deficits.  He 
meets criteria for use of a power mobility device.  The requested accessories are not medically necessary as he 
does have use of his hands and can operate and control the power options using the switches that are included 
in the basic wheelchair. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve wheelchair options.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the use of this 
drug/regimen is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that that 
the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found that the FDA has not stated that the requested drug is indicated for the enrollee's 
specific clinical condition. The Medicare approved cancer drug compendia do not contain a supportive citation 
for the use of the requested drug in the enrollee's clinical situation and no literature from Medicare approved 
cancer journals were submitted for review. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) rendered by 
the out-of-network (OON) provider on January 14, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the targeted genomic sequence analysis (0037U) rendered by the out-of-network 
(OON) provider on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on April 8, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on April 8, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit (J0885) for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of this drug is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that 
the enrollee has a diagnosis of aplastic anemia. The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain 
a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the 
coverage criteria are not satisfied. 
 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Procrit (J0885) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740), core buildup, including any pins when 
required (D2950), and gingivectomy or gingivoplasty (D4212) provided on November 15, 2021. 
 
You asked the Plan to pay for the crown, core buildup, and gingivectomy or gingivoplasty. You say that you 
charged the entire amount of $1,218.00 to your credit card with the understanding that you would be 
reimbursed 50% of the cost. 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740), core buildup, including any pins when required (D2950), and gingivectomy or gingivoplasty (D4212) 
provided on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) and 
panoramic x-ray (D0330) provided on October 12, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays and panoramic x-ray. You say that you do 
not understand what services your insurance covered. The Plan denied your request. The Plan says these 
services are not covered under your plan. 
 
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 record shows that your insurance covered the comprehensive oral 
evaluation (D0150) and prophylaxis (D1110). Therefore, we decided that the Plan does not have to pay for the 
complete series of intraoral x-rays (D0210) and panoramic x-ray (D0330) provided on October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this equipment is medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass frames (V2020) and bifocal eyeglass lenses 
(V2203) purchased November 30, 2021. 
 
You asked the Plan to pay for the vision services. You say that since your old frames were obtained in 2017, 
you should be due for a benefit on the new frames. The Plan denied your request. The Plan says the claim was 
processed with the correct cost share applied. 
 
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 there is a $150 
allowance, every 24 months for eyewear. If the eyewear you purchase cost more than $150, you pay the 
difference.  
 You had already paid the $93 for the vision services. The contract specifically says if the eyewear you purchase 
cost more than $150, you pay the difference The vision services fall within the Vision 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 pay for the eyeglass frames (V2020) and bifocal eyeglass lenses (V2203) purchased 
November 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infrared therapy provided from October 5, 2021, through 
October 8, 2021. 
 
You asked the Plan to pay for Infrared therapy. The Plan denied your request. The Plan says Infrared therapy is 
considered not reasonable and necessary by Medicare and is excluded from coverage.  
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for Infrared therapy provided from October 5, 2021, through  
October 8, 2021.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 [the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the office visit (99203) provided on  
August 4, 2021. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
service 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 $10 copayment for services obtained from a 
specialist or under certain circumstances, treatment by a nurse practitioner or physicians assistant or other  
non-physician health care professionals in a specialists office. Additionally, your in-network and out-of-
network medical deductible for the year 2021 is $500. This is the amount you have to pay out-of-pocket before 
the Plan will pay their share for your covered medical services. 
 
You have been asked to pay $72.48 ($62.48 + $10) for the specialist office visit provided. This amount 
includes a $10 copayment for office visit provided by a specialist. Additionally, this amount includes a $62.48 
deductible applied as you had not previously met the annual deductible. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the cost share for the office visit (99203) provided on August 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for surgical services provided from September 
27, 2021, to September 30, 2021. 
 
You asked the Plan to waive the coinsurance for the surgical services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied 
correctly based on 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 20% 
coinsurance for Prosthetic devices and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for surgical services (total $1,552.56). Surgical services fall 
within the Prosthetic devices and related supplies 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 surgical services provided from September 27, 2021, to September 30, 2021.