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

 
We decided that the Plan does not have to waive the copayment and coinsurance for a nuclear stress test and 
the injections provided on December 9, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for a nuclear stress test and injections. You say 
that the plan should cover these charges. The Plan denied your request. The Plan says the cost share 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 $100 
copayment for Medicare-covered Nuclear Medicine at a freestanding provider and 20% coinsurance for 
Medicare Part B-covered chemotherapy drugs and other Medicare Part B covered drugs (including certain 
drugs that are used with nebulizers, insulin pumps, and IV infusion pumps).  
 
You have been asked to pay a total of 147.89 which consists of the $100 copayment and 20% coinsurance 
($47.89). The nuclear stress test falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. The injections 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 copayment and coinsurance for a nuclear stress test and the injections 
provided on December 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the tilt in wheelchair (CPT code E1161). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says there has been no specialty evaluation performed by a licensed/certified medical 
professional (LCMP), such as a Physical Therapy or Occupational Therapy, or a clinician who has specific 
training and experience in rehabilitation wheelchair evaluations, and that documents the medical necessity for 
the wheelchair and its special features. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Per the Medicare guidelines, durable medical equipment like wheelchairs may be covered for members who 
will use it in their home, which is defined as the member's own dwelling, an apartment, a relative's home, a home for the aged, or certain other institutions such as assisted living facilities or intermediate care facilities for 
members with intellectual disabilities. However, an institution is not considered a member's home if it meets at 
least the basic requirements in the definition of a SNF, meaning it is primarily engaged in providing skilled 
nursing care and related services on an inpatient basis for those who require medical or nursing care or 
rehabilitation services for injured, disabled, or sick people. If a member is inpatient at a SNF, they are not 
entitled to separate Medicare Part B payment for durable medical equipment because the institution may not be 
considered their home. Based on the information we received, the enrollee resides in long-term care at a SNF.  
Therefore, we decided that the Plan does not have to pre-approve the tilt in wheelchair (CPT code E1161).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays taken on March 11, 2022. 
 
You asked the Plan to waive the copayment for x-rays taken on March 11, 2022. You say that you should not 
be responsible for this copayment. The Plan denied your request. The Plan says enrollees must pay a $15 
copayment for x-rays performed in a physician's office or Independent Diagnostic Testing facility (IDTF). 
 
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 $15 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $15 copayment for x-rays taken on March 11, 2022. X-rays fall 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 x-rays taken on March 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a repeat epidural steroid injection (ESI). 
 
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. Medicare rules say that a repeat ESI is covered when specific criteria are 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the records show that you have chronic low 
back pain and had prosthetic disc placement at two levels. You had a trial of physical therapy in 2020 that did 
not help. You had an ESI on March 10, 2022 that provided 80 percent pain relief for three months. You had 
sustained relief from the last injection. The criteria for coverage of a repeat ESI are met and the services are 
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 a repeat epidural steroid injection (ESI).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Emgality. 
 
You asked the Plan to pre-approve Emgality. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Emgality.  
 
Benefits for Emgality 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: 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 enrollee is medically ready for discharge from 
the current facility, but due to the severity of the enrollee's condition, transfer to an IRF is necessary. The Plan 
denied your request. The Plan says the requirements for admission to an IRF have not been met. There is no 
documented need indicating that services be provided by an interdisciplinary medical team. The enrollee's 
needs can be safely and effectively managed at a lower level of care. 
 
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 meet the requirements for care in an 
IRF. The enrollees medical problems are stable and there are no complex nursing or rehabilitation needs that 
would require admission to an IRF. Our reviewer also found that there is no reasonable expectation that the 
enrollee would be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. The enrollees physical and/or occupational therapy needs do not require the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Dupixent is a self-administered drug and is not covered by Part B benefits. 
 
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 Dupixent injection.  
 Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240) and a raised toilet seat (E0244). 
 
You asked the Plan to pre-approve a shower chair and toilet seat. You say that you are in need of these items 
due to your age. It was prescribed by your doctor and is medically necessary due to your condition. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240) and a raised 
toilet seat (E0244).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement group 1, power operated vehicle, electric 
scooter (K0800). 
 
You asked the Plan to pre-approve an electric scooter replacement. You say that you have had your scooter for 
4 years and when you charge the scooter it is only able to be used for 10 minutes and does not work after that. 
Your scooter is deteriorated, and you need a new scooter. The Plan denied your request. The Plan says you do 
not qualify for replacement of an electric scooter. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at the file, and Medicare rules. Medicare covers this item once every 5 years.  The records show that 
you received the electric scooter on November 20, 2019. You will qualify for replacement on November 20, 
2024.  Based on this information, we decided that Medicare rules for coverage of a electric scooter replacement 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement group 1, 
power operated vehicle, electric scooter (K0800).
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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital for altered mental status and a urinary tract infection.  He is now medically stable with no complex nursing or rehabilitation needs. He does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While he has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. There is not a reasonable expectation that 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the 
requested drug has not been prescribed for a medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a diagnosis of ovarian cancer that does not exhibit tumor mutational burden-high (TMB-H) (=10 
mutations/megabase [mut/Mb]) disease, microsatellite instability-high (MSI-H), or mismatch repair deficient 
(dMMR) disease. The 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. No literature from Medicare-approved cancer journals were submitted for review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive your $10 copayment for an office visit on February 2, 2022. 
 
You asked the Plan waive your $10 copayment for an office visit on February 2, 2022. You say that you were 
seen for a preventative checkup, and you should not be responsible for this copayment. The Plan denied your 
request. The Plan says enrollees pay a $10 copayment for each primary care doctor visit. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
 
 
 
 
 
 
 You have been asked to pay a $10 copayment for an office visit on February 2, 2022. An office visit falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. Please note: the 
provider billed this as an office visit. 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 waive your $10 copayment for an office visit on 
February 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you were unaware the provider was not in-
network. The Plan denied your request. The Plan says there are several available in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
orthopedic services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system. 
 
You asked the Plan to pre-approve a Volara system. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is a deluxe product used for convenience. 
 
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 a Volara system. Our reviewer says that 
the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record shows that you currently have a Vest system for airway clearance. The Volara system has 3 
components: nebulization, positive airway pressure for "lung expansion," and airway oscillation. There is no 
evidence that this device is any more effective for airway clearance than the Vest system or other clearance 
measures. You currently also have a nebulizer, making that component is redundant. 
 
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 Volara system. have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Volara system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient surgery performed on 
November 16, 2021, or the copayment for physical therapy on November 16, 2021. 
 
You asked the Plan to waive the coinsurance for surgery performed on November 16, 2021. You say that you 
thought these services would be billed as inpatient services. The Plan denied your request. The Plan says you 
pay a 20% coinsurance for surgery at an outpatient hospital facility. 
 
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 outpatient surgery. Your contract with the Plan also clearly says that you must pay a $40 
copayment for outpatient physical therapy.  You have been asked to pay $2236.53 for surgery performed on November 16, 2021. The allowed amount for  
this surgery is $11,182.679 ($11,182.67 x 20% = $2236.53). 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.   
 
You have also been asked to pay a $20.16 copayment for physical therapy provided on November 16, 2021.  
The Plan contract says you must pay a $40 copayment for outpatient physical therapy. You have been asked to 
pay less than the amount stated in 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 outpatient physical therapy performed on November 16, 2021.