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

 
We decided that the Plan has to pre-approve Gazyva. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has refractory chronic 
lymphocytic leukemia (CLL) diagnosed in 2013. A single-agent Gazyva has demonstrated PR rates of 
approximately 50 percent in patients with relapsed or refractory CLL. The Gazyva is safe and effective and 
medically necessary 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve Gazyva.  
 
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 waive the coinsurance for oxygen concentrator on April 25, 2021, to 
March 25, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen concentrator. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a 20% 
coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies. Covered items 
include, but are not limited to wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital bed 
ordered by a provider for use in the home, IV infusion pumps, speech generating devices, oxygen equipment, 
nebulizers, and walkers. The provider billed in the amount of $335 and the allowed amount is $122.12. $122.12 
x 20% = $24.42. There were 12 dates of service. 12 x $24.42 = $293.04. Therefore, results in the total cost 
sharing amount of $293.04.  
 You have been asked to pay a 20% coinsurance for oxygen concentrator. Oxygen concentrator falls within the 
Durable medical equipment (DME) 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 oxygen concentrator on April 25, 2021, to March 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 26, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service April 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 15, 2021, to 
March 24, 2021. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, March 15, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from March 15, 2021, to March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from May 7, 2021, through May 
11, 2021, at DRG 291. 
 
You asked the Plan to pay for inpatient services at DRG 291. You say that the diagnosis is supported by the 
coding guidelines, documentation, clinical indicators and treatment as documented. You say that DRG 291 
should be reconsidered. The Plan denied your request. The Plan says diagnosis code E87.1 is a valid diagnosis 
and diagnosis code J96.01 could not be validated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J96.01, defined as acute respiratory 
failure, not elsewhere classified Type 2 [with hypercapnia]. 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 inpatient services. Our reviewer says that the documentation does not support diagnosis code 
J96.01. Our physician reviewer found that oxygen was ordered as needed at the time of admission but there 
was no documentation that the enrollee was oxygen dependent. The physician documented no acute distress in 
the history and physical and progress notes.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from May 7, 2021, through May 11, 2021, at DRG 291.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that no medical records were provided to support the services billed. 
This means that the documentation does not support that the laboratory testing at issue in this appeal was not 
requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 2, 
2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to waive the copayment for ophthalmological services provided on May 2, 2022. 
 
You asked the Plan to waive the copayment for ophthalmological services. You say that this was a routine eye 
exam and should not be billed $40. You also say that the Plan states a $0 copayment for a routine eye exam. 
The Plan denied your request. The Plan says that says you were charged the correct cost sharing amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan claims it was a diagnostic exam and not a routine exam, but the Plan 
did not provide any records to prove that diagnostic services were conducted. Therefore, we decided that the 
Plan has to waive the copayment for ophthalmological services provided on May 2, 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 waive the copayment for office visit on May 16, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $25 
copayment for each specialist's office visit.  
 
 
 
 
 
 
 
 
 You have been asked to pay a $25 copayment for office visit. Office visits fall within the Outpatient surgery, 
including services provided at hospital 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 office visit on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair accessory, electronic connection 
(E2311), a power wheelchair accessory, expandable controller (E2377) and a power wheelchair accessory, 
expandable controller harness (E2313). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the enrollee has CTS and 
requires the requested accessories due to carpal tunnel syndrome limiting her ability to grab small items. You 
also say manipulating multiple small switches to control the needed power functions of the chair would be 
nearly impossible, causing her unneeded pain and frustration. The Plan denied your request. The Plan says the 
requested accessories are not medically necessary. 
 
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 power wheelchair accessories. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found provided contemporaneous medical records do not document why the 
electronic connection, expandable controller and expandable controller harness at issue in this case are 
medically necessary. A letter from the enrollee's medical provider written after the health plan denied the 
requested accessories argues necessity of the electronic connection, expandable controller and expandable 
controller harness but the contemporaneous medical records do not contain adequate documentation to meet 
Medicare criteria for coverage. Provided records document that the enrollee has 3+/5 upper extremity strength 
thus indicating she has adequate upper extremity strength to operate the wheelchair's power options with their 
own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power wheelchair accessory, electronic connection (E2311), a power 
wheelchair accessory, expandable controller (E2377) and a power wheelchair accessory, expandable controller 
harness (E2313).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2022. 
 You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that no medical records were provided with the case file. This means that the 
documentation does not support that the laboratory testing at issue in this appeal was not requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the laboratory services provided on February 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH criteria. The 
Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do not 
meet the requirements for approval. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network dermatology visit 
provided on December 16, 2021. 
 
You asked the Plan to waive the copayment for an out-of-network dermatology visit. You say that you were 
told this provider was in network, therefore, you should not have to pay this copayment. The Plan denied your 
request. The Plan says the copayment was applied correctly. The provider has been out-of-network since 2020. 
 
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 $60 
copayment for physician/practitioner services, including visits.  
 
 
 
 
 
 
 You have been asked to pay a $60 copayment for an out-of-network dermatology visit. An out-of-network 
dermatology visit falls within the Physician/Practitioner Services, Including 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 out-of-network dermatology visit provided on December 16, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a radiation treatment provided on March 7, 
2022. 
 
You asked the Plan to waive the copayment for a radiation treatment. You say that you were unaware of these 
copayments, and they will cause a financial hardship. The Plan denied your request. The Plan says the 
copayments that were applied were 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 $60 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $60 copayment for a radiation treatment. A radiation treatment falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and 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 copayment for a radiation treatment provided on March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet joint (or nerves innervating that joint) with image guidance (64493) and injection(s), 
diagnostic or therapeutic agent, paravertebral facet joint (or nerves innervating that joint) with image guidance 
(64494). 
 
You asked the Plan to pre-approve injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says the requested injections do not meet the requirements for approval. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has had epidural steroid injections, trigger point injections as well as physical 
therapy. She had a facet joint block that produced 50% pain relief but was short-lived. The request is to repeat 
the block. The amount of pain relief does not meet the LCD criteria and therefore, the request is considered 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet joint (or nerves innervating that 
joint) with image guidance (64493) and injection(s), diagnostic or therapeutic agent, paravertebral facet joint 
(or nerves innervating that joint) with image guidance (64494).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH criteria. The 
Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve the requested testing. The Plan denied your request. The Plan says the 
enrollee does not have identified risk factors for germline cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that BRCA1 and BRCA2 genetic testing 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 request to pre-approve the requested testing. Our physician reviewer found that the enrollee has 
newly diagnosed stage II breast cancer. The enrollee is not triple negative. There is no family history of breast, 
ovary, prostate, or pancreas cancers. BRCA testing is not needed to guide therapy. Therefore, the request is 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 requested testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genetic testing.