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

 
We decided that the Plan does not have to waive the copayment for the SNF stay provided from January 11, 
2022, to February 3, 2022. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that the enrollee was told if he left 
without permission, his insurance wouldn't pay for his stay, which is the only reason he stayed. The Plan denied 
your request. The Plan says the copayment was applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay, for days 1-20, a $0 copayment per day and for days 21-100, a $188 copayment per day.  
 
 
  The enrollee has been asked to pay $564 for the SNF stay. The SNF stay falls within the Skilled Nursing 
Facility (SNF) Care benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
skilled nursing facility (SNF) stay provided from January 11, 2022, to February 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxaliplatin, gemcitabine, durvalumab, dexamethasone, 
palonosetron, ondansetron, aprepitant. 
 
You asked the Plan to pre-approve the medications. You say that the medications are necessary. The Plan 
denied your request. The Plan says the use of this drug (durvalumab) in the enrollee's case requires a regimen 
of gemcitibine, cisplatin, and durvalumab. The Plan states the enrollee not meet these requirements and the 
information submitted indicates the enrollee is using a regimen of gemcitibine, oxaliplatin, and durvalumab. 
 
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 medications. Our physician 
reviewer found the requested use of oxaliplati, gemcitabine, durvalumab, dexamethasone, palonosetron, 
ondansetron, and aprepitant is not Food and Drug Administration (FDA)-approved for the enrollees diagnosis. 
The use is not supported by one of the major drug compendia or by clinical research that appears in a Centers 
for Medicare & Medicaid Services (CMS)-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 the medications have not been met. Therefore, we decided that the Plan does 
not have to pre-approve oxaliplatin, gemcitabine, durvalumab, dexamethasone, palonosetron, ondansetron, 
aprepitant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bilateral, lumbo-sacral, hip, femur orthosis provided on 
March 21, 2022. 
 
You asked the Plan to pay for bilateral, lumbo-sacral, hip, femur orthosis. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the item rendered is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the records do not state that the enrollee has a diagnosis of a left or 
right hip sprain. The documentation did not include records stating that the provider prescribed or even 
considered this brace for the enrollee. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
bilateral, lumbo-sacral, hip, femur orthosis provided on March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet joint RFA procedure (CPT code(s): 64636 
x2 and 64635 x1). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found you have lumbar radiculopathy, and your last RFA did not result in any pain relief. Therefore, the 
request does not meet LCD criteria and is deemed 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 lumbar facet joint RFA procedure (CPT code(s): 64636 x2 and 64635 x1).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office or other outpatient visit for the 
evaluation and management of an established patient (99213), fundus photography with interpretation and 
report (92250), and determination of refractive state (92015) provided February 4, 2022. 
 
You asked the Plan to waive the copayment for the office visit and vision services. You say that you feel you 
were overcharged for your office visit. The Plan denied your request. The Plan says the copayment was applied 
correctly. The Plan also says that they have contacted the Provider who has indicated they will not bill the 
additional $45 for the refraction. 
 
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 $35 
copayment for each Medicare-covered eye exam. 
 You have been asked to pay a $35 copayment for the vision services. The office visit and vision services fall 
within the Vision 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 the office or 
other outpatient visit for the evaluation and management of an established patient (99213), fundus photography 
with interpretation and report (92250), and determination of refractive state (92015) provided February 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the myocardial perfusion imaging 
provided on December 31, 2021, and cardiac rhythm monitor insertion provided on January 28, 2022. 
 
You asked the Plan to waive the coinsurance for the myocardial perfusion imaging and cardiac rhythm monitor 
insertion. You say that it was your understanding that these services had been approved. The Plan denied your 
request. The Plan says you have been charged the correct coinsurance 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 you must pay 40% of the 
total cost for outpatient diagnostic tests and outpatient surgery from an out-of-network provider. 
 
You have been asked to pay a total of $3751.57 for the myocardial perfusion imaging and cardiac rhythm 
monitor insertion. 
 
Date of Service Service Allowed Amount Coinsurance Member Liability 
December 31, 2021 Myocardial 
Perfusion Imaging 
$1,277.03 40% $510.81 
January 28, 2022 Cardiac Rhythm 
Monitor Insertion 
$8,101.90 40% $3,240.76 
TOTAL:    $3751.57 
 
The myocardial perfusion imaging falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. The cardiac rhythm monitor insertion falls within the Outpatient Surgery, Including 
Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 the myocardial perfusion imaging provided on December 
31, 2021, and cardiac rhythm monitor insertion provided on January 28, 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 documentation does not support the medical necessity for admission to 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on March 25, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were unaware you would 
be billed as outpatient so this should be waived. The Plan denied your request. The Plan says the copayment 
applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $350 
copayment per visit to an outpatient hospital facility or ambulatory center. 
 
You have been asked to pay $350 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 outpatient surgery provided 
on March 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate 2.5mg tablets. 
 
You asked the Plan to pre-approve Methotrexate. You say that the Methotrexate is medically necessary. The 
Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methotrexate 2.5mg tablets.  
 
Benefits for Methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. 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 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 Durolane. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no indication that the enrollee has 
tried and failed the required drug. Based on the medical records provided and the Medicare-approved major 
drug compendia there is no indication that the plan's required drug(s) 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT code 63650) and implantable neurostimulator electrode (CPT code L8680). 
 
 You asked the Plan to pre-approve the outpatient procedure. You say that the outpatient procedure is needed. 
The Plan denied your request. The Plan says the enrollee's request is not medically necessary because their 
records show they do not have documented evaluation by a multidisciplinary team including a psychological 
screening. 
 
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 outpatient procedure. Our physician 
reviewer found detailed documentation is not evident regarding this being a late and/or last resort for this 
enrollee. Additionally, it is documented that the enrollee has tried and failed a previous spinal cord stimulator 
(SCS) trial with Medtronic. Details of this failed trial were not provided for review. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, medical records provided do not meet the requirements listed in the NCD 
for Medicare coverage. 
 
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 outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 
63650) and implantable neurostimulator electrode (CPT code L8680).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 documentation does not support the medical necessity for admission to 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle orthosis and the foot/heel stabilizer provided on 
March 21, 2022. 
 
You asked the Plan to pay for the ankle orthosis and the foot/heel stabilizer. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the records do not state that the enrollee had a diagnosis of left ankle 
sprain. There is no documentation that these items were prescribed, or even considered for the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the ankle orthosis and the foot/heel stabilizer 
provided on March 21, 2022.
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. The enrollees care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chemotherapy treatment of carboplatin, pembrolizumab 
1 milligram, and Pemetrexed 10 milligrams (CPT code(s): J9304, J9045, J9271). 
 
You asked the Plan to pre-approve the medication. You say that the medication regimen is necessary. The Plan 
denied your request. The Plan says the enrollee's doctor's notes do not show they have had another test (repeat 
molecular testing). The Plan states the enrollee's doctor's notes do not show why the enrollee has not had this 
testing; therefore, these medicines are 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 the medication. Our physician reviewer 
found the requested use of carboplatin, Pembrolizumab 1 milligram, and Pemetrexed 10 milligrams is not Food 
and Drug Administration (FDA)-approved for the enrollees diagnosis. The use is not supported by one of the 
major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services 
(CMS)-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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chemotherapy treatment of carboplatin, pembrolizumab 1 milligram, and Pemetrexed 10 
milligrams (CPT code(s): J9304, J9045, J9271).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a clinic visit received on October 12, 2021. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says you are responsible for this copayment. 
 
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 $25 
copayment for specialist office visits.  
 
You have been asked to pay a $25 copayment for the visit. The visit falls within the specialist 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 pay for a clinic visit received on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first periapical x-ray (D0220) and additional periapical x-
rays (D0230 x 2) provided on March 22, 2022. 
 
You asked the Plan to pay for the x-rays. You say that you thought the x-rays were covered. The Plan denied 
your request. The Plan says a periapical x-ray (D0220) and additional periapical x-rays (D0230) are not 
covered by your dental benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first 
periapical x-ray (D0220) and additional periapical x-rays (D0230 x 2) provided on March 22, 2022.