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

 
We decided that the Plan does not have to pre-approve treatment with Jemperli (J9272). 
 
You asked the Plan to pre-approve Jemperli. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug has been prescribed for an off-label, 
not medically accepted use. 
 
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 Jemperli. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Jemperli is not FDA-approved for the enrollees diagnosis. Additionally, the use is not 
supported by one of the major drug compendia or by clinical research that appears 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 Jemperli have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Jemperli (J9272).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance skilled nursing facility provided on April 1, 
2022, to April 14, 2022. 
 
You asked the Plan to waive the coinsurance skilled nursing facility. You say that you are disputing the cost 
share. The Plan denied your request. The Plan says this cost sharing was charged 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 50% 
coinsurance for skilled nursing facility care. The allowed amount of this skilled nursing facility total $6,327.11, 
resulting in a coinsurance amount of $3,163.55. 
 
You have been asked to pay 50% coinsurance for skilled nursing facility. This item/service falls within the 
skilled nursing facility 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 coinsurance skilled nursing 
facility provided on April 1, 2022, to April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve block. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation to support whether the provider has assessed the effectiveness 
of the treatments or any other alternative treatment. 
 
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 the block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, you have previously undergone a diagnostic nerve block for occipital neuralgia, so you 
would not meet criteria for coverage of an occipital nerve block for this diagnostic indication. Based on the 
other information provided for review the requested nerve blocks have previously been performed/completed. 
You have had more than three nerve blocks in a six-month period, which would otherwise exceed the 
limitations of the guidelines for coverage of this service. Additionally, there was no documentation regarding 
the efficacy of the treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a peripheral nerve block.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for cytogenetics testing (88291) provided on April 22, 2022. 
 
You asked the Plan to pay for cytogenetics testing. You say that the service at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan follows Medicare rules. The rules say that Medicare covers cytogenetic tests when they are 
reasonable and necessary for the diagnosis or treatment of the conditions listed in the Medicare rules section of 
this letter. 
 
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 cytogenetics testing. Our reviewer says that 
the service at issue is medically reasonable and necessary in this case. Our physician reviewer found that 
myelodysplasia is a covered indication for molecular testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cytogenetics testing have been met. Therefore, we decided that the Plan has to 
pay for cytogenetics testing (88291) provided on April 22, 2022.  
 
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 pre-approve a minimally invasive lumbar decompression (MILD) 
procedure. 
 
You asked the Plan to pre-approve a MILD procedure. You say that the services are necessary. The Plan denied 
your request. The Plan says the enrollee is not part of a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for dates of service specified below, the 
Centers for Medicare & Medicaid Services (CMS) has determined that PILD will be covered by Medicare 
when provided in a clinical study under section 1862(a)(1)(E) of the Social Security Act (the Act) through 
Coverage with Evidence Development (CED) for beneficiaries with LSS who are enrolled in an approved 
clinical study. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a MILD procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve a minimally invasive lumbar decompression (MILD) procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for zoll life vest provided on June 17, 2022. 
 
You asked the Plan to waive the coinsurance for zoll life vest. You say that you should not have to pay the cost 
share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment and related supplies. The allowed amount of the vest total 
$2,772.86, resulting in a coinsurance of $554.57. 
 
You have been asked to pay 20% coinsurance for zoll life vest. This item/service falls within the durable 
medical equipment 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 zoll life vest provided on June 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 3, 2022, billed with 
multiple codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 3, 2022, billed with multiple codes.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision supply, accessory provided on June 28, 2022. 
 
You asked the Plan to pay for vision supply, accessory. The Plan denied your request. The Plan says vision 
supply, accessory is not a covered benefit. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and the Plan's rules. The file shows that the Plans routine vision benefit does not provide 
coverage for vision supplies and accessories. Therefore, we decided that the Plan does not have to pay for 
vision supply, accessory (code V2797) provided on June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics purchased March 8, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that foot orthotics were medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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.   
 
The medical 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 pay for foot orthotics purchased March 
8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has complex medical and rehabilitation 
needs. The Plan denied your request. The Plan says based on Medicare guidelines the inpatient rehabilitation 
facility services you are requesting do not meet the requirements for approval. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for a below the knee amputation. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical or occupational therapy, and an intensive rehabilitation therapy program. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an IRF can provide medically necessary 
treatment you need. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and you can get the care you need in another setting. 
 
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 that you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The health plan has approved ongoing care in the current acute 
care setting. 
 
   
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 LTACH services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve the comprehensive metabolic panel rendered on April 20, 2022. 
 
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 were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the services were medically necessary. Our physician reviewer found the enrollee was seen for Type II diabetes 
with hyperglycemia and underwent blood work performed at the hospital-based laboratory. The comprehensive 
metabolic panel (CMP) is used as a broad screening tool to evaluate the health of organs and to screen for 
conditions such as diabetes, liver disease, and kidney disease. The testing was 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 the comprehensive metabolic panel rendered on April 20, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic CGM. You say that this device is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage of the requested CGM have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hearing aid (V5221), dispensing fee (V5241), and 
fitting (V5011). 
 
You asked the Plan to pre-approve a hearing aid, dispensing fee, and fitting. 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 does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only [Insert why/when the plan covers hearing aids].  
 
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 a hearing aid, dispensing fee, and 
fitting. Our reviewer says that the services are not medically necessasy. Our physician reviewer found the 
review has determined that the items/services at issue in this case are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of a hearing aid, dispensing fee, and fitting have not been met. Therefore, we decided that the Plan does not have to pre-approve a hearing aid (V5221), dispensing fee (V5241), and fitting 
(V5011).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services with no transport provided on May 3, 
2022. 
 
You asked the Plan to pay for the services. You say that proper action should be taken after reviewing the 
medical records. The Plan denied your request. The Plan says this is not a covered benefit because the enrollee 
was not transported to the hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 3, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services with no transport provided on 
May 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health aide services. 
 
You asked the Plan to pre-approve the services. You say that without these services, you feel that you are at 
increased risk for readmission to the hospital. The Plan denied your request. The Plan says the records do not 
show a skilled need. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the services of 
a home health aide are not shown to be medically necessary to assist in the treatment of illness or injury. You 
appear to be highly functional, bathing nearly independently, and attending medical appointments. 
Furthermore, you have a caregiver available for assistance and supervision. As such, the requested aide services are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional home health aide services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve darbepoetin alfa (J0885). 
 
You asked the Plan to pre-approve darbepoetin alfa. You say that the requested drug is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested drug is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all drugs and biologicals used for the treatment 
of ESRD are included in the ESRD PPS and are not separately paid as of January 1, 2011. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of darbepoetin alfa have not been met. Therefore, we decided that the Plan does not have to pre-
approve darbepoetin alfa (J0885).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on May 10, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that this should be covered. The Plan 
denied your request. The Plan says there was no preauthorization by a primary care provider (this is different 
than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 an outpatient mental health visit provided on May 
10, 2022, by an out-of-network (OON) provider.