Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you have Alzheimers, and you forget to 
check your blood glucose. The Plan denied your request. The Plan says that you do not meet criteria for 
coverage. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
February 12, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that the heat was not working 
properly in your room. You say that you should not be responsible for the copayment. 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 $325 
copayment for each inpatient stay.  
 
You have been asked to pay a $325 copayment for the inpatient care. The inpatient care falls within the 
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 care provided on February 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that a kyphoplasty is medically necessary. The Plan 
denied your request. The Plan says a kyphoplasty is not medically necessary based on the Medicare LCD 
coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 kyphoplasty. Our reviewer says that a 
kyphoplasty is not medically necessary. Our physician reviewer found that there is bone retropulsion on 
imaging. A kyphoplasty is not indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out-of-network mental health services provided from January 
4, 2022, to February 16, 2022. 
 
You asked the Plan to pay for the out-of-network mental health services. You say that prior to enrolling in 
Medicare, you were able to get these services covered as an out-of-network service. You said that these 
services are important; and you do not want to go to another provider. The Plan denied your request. The Plan 
says this provider has opted out of Medicare and therefore these services cannot be paid. 
 
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 out-of-
network mental health services provided from January 4, 2022, to February 16, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested drug is medically necessary for the 
enrollee's treatment of anemia in chronic kidney disease. The Plan denied your request. The Plan says the 
enrollee has not met the step therapy criteria for coverage. 
 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 Injectafer. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug Infed 
and Venofer before they will approve the requested drug. In this case, the enrollee has 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 the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Ilumya. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of plaque psoriasis. The enrollee has tried and failed topical clobetasol and 
triamcinolone and cannot take methotrexate. The documentation does not support that the enrollee has tried and 
failed Remicade, Inflectra or infliximab and Stelara. The documentation does not support that Remicade, 
Inflectra, infliximab, or Stelara would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the requested drug does not meet step therapy criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray provided on January 11, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for x-ray. You say that you are appealing the claim payment denial. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not approved in advanced. 
 
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 x-ray at issue in this appeal. The Plan did not pre-approve the x-ray at 
issue. We found no exception that would require the Plan to pay for the x-ray. Therefore, we decided that the 
Plan does not have to pay for x-ray provided on January 11, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and administration 
provided on January 26, 2022. 
 
You asked the Plan to waive the coinsurance for the chemotherapy drugs and administration. You say that you 
cannot afford the coinsurance. The Plan denied your request. The Plan says the correct coinsurance was 
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 must pay a 20% 
coinsurance for Part B chemotherapy drugs, including drug administration. 
 
 
 
 
 
 
 Service/Drug Allowed Amount 20% Coinsurance 
Chemotherapy Infusion 1 Hr $125.75 $25.15 
Chemotherapy Infusion Addl Hr $27.14 $5.43 
Chemotherapy Infusion Addl Seq $122.96 $24.59 
Palonosetron $8.60 $1.72 
Pertuzumab $5,695.20 $1,139.04 
Kanjinti $1,706.76 $341.35 
Fosaprepitant $28.50 $5.70 
Docetaxel $33.12 $6.62 
Total:  $1,549.60 
 
You have been asked to pay $1,549.60, which is 20% of the allowed amount for the chemotherapy drugs and 
administration. The chemotherapy drugs and administration fall within the Medicare Part B Prescription Drugs 
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 chemotherapy drugs and 
administration provided on January 26, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services (90715, 90471, G0168) provided 
on February 14, 2022. 
 
You asked the Plan to pay for outpatient services. You say that this claim was billed with valid codes, and this 
claim should be paid. The Plan denied your request. The Plan says G0168 was reported on this claim, but this 
code has a payment status indicator of "B", which means that it is not recognized by OPPS. According to 
I/OCE edit instructions, edit 62 applies in this case, and the whole claim is returned to the provider for 
correction. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that when a code with a 
status indicator of B is reported on an OPPS 13x bill type, then the whole claim is rejected and returned to 
the provider for correction. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient services have not been met. Specifically, this claim was billed with code G0168, which 
has a payment status indicator of B. That means that the claim is returned to the provider, and this line must 
be corrected before any part of this claim can be paid. Therefore, we decided that the Plan does not have to pay 
for outpatient hospital services (90715, 90471, G0168) provided on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the health club membership (S9970) 
provided January 1, 2022, through February 28, 2022. 
 
You asked the Plan to provide additional payment for the health club membership. You say that you would like 
to be reimbursed your remaining Wellness Allowance. The Plan denied your request. The Plan says you have 
been correctly reimbursed for your January and February health club benefits. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
up to $150 per calendar year. 
 
Documentation in the case file provides proof of payment to the health club for January and February 2022 for 
$69 per month. The Plan has reimbursed a total of $138 for your 2022 Wellness Allowance. There is no proof 
of payment for any additional amount beyond $138 for the 2022 year. Therefore, we decided that the Plan does 
not have to provide additional payment for the health club membership (S9970) provided January 1, 2022, 
through February 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc solution (J7327). 
 
You asked the Plan to pre-approve Monovisc. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthovisc, Synvisc, 
or Synvisc One. 
 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 Monovisc. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs, Orthovisc, Synvisc, or Synvisc One. The 
reviewer also found that the documentation does not support that the preferred drugs would likely be less 
effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found 
that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc solution (J7327).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the subsequent hospital care (99232) provided from July 28, 2021, 
through August 2, 2021. We decided that the Plan does not have to pay for the subsequent hospital care 
(99232) provided on July 27, 2021, and discharge management services provided on August 3, 2021.  
 
You asked the Plan to pay for subsequent hospital care and discharge management services. The Plan says that 
the documentation does not support this level of service for the subsequent hospital care provided from July 27, 
2021, through July 31, 2021. The Plan also says the services provided from August 1, 2021, through August 3, 
2021, are not covered because coverage had been terminated. 
 
We decided that the Plan has to pay for the subsequent hospital care (99232) provided from July 28, 
2021, through August 2, 2021.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request coverage. Our reviewer says that the level of service in the medical 
records support an expanded problem focused history, a comprehensive exam and medical decision making of 
low complexity. In addition, the subsequent hospital care provided in August is eligible for coverage since the 
enrollee was eligible for coverage when the hospital stay began. 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 pay for 
the subsequent hospital care (99232) provided from July 28, 2021, through August 2, 2021.  
 
We also decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on 
July 27, 2021, and discharge management services provided on August 3, 2021. 
 
Our reviewer says that the criteria for coverage of these services have not been met. Our reviewer found that 
there is a more appropriate code to report for the service provided July 27, 2021. In addition, the medical 
record does not support a hospital discharge service was performed. Therefore, we decided that the Plan does 
not have to pay for the subsequent hospital care (99232) provided on July 27, 2021, and discharge management 
services provided on August 3, 2021. 
 
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 a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically reasonable and necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been satisfied. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service October 22, 
2020. 
 
You asked the Plan to pay for procedure code 70480. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70480 is bundled into 
payment for code 70450. 
 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, we have confirmed that code 70480 
is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70480 billed for date of service October 22, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jemperli injection (J9271). 
 
You asked the Plan to pre-approve Jemperli. 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 medically 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 Jemperli. Our reviewer says that the 
requested drug, Jemperli, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's 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. Therefore, the reviewer found that the requested drug is not medically 
necessary in this case. 
 
 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 Jemperli injection (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit care provided from February 4, 2022, to February 
21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for office visit care. You say that this provider takes this Plan. The Plan denied your 
request. The Plan says these services from non-participating providers for office visit services are not covered 
under your plan unless they are authorized by the Plan before the services are provided. 
 
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 office visit care provided from February 4, 2022, 
to February 21, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye appointment provided on February 
22, 2022. 
 
You asked the Plan to waive the copayment for an eye appointment. You say that the copayment was not 
accepted through your payflex card. The Plan denied your request. The Plan says the copayment applied was 
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 for specialist Physician/Practitioner services.  
 
You have been asked to pay a $30 copayment for an eye appointment. An eye appointment 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 an eye appointment provided on February 22, 2022.