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

 
We decided that the Plan does not have to pre-approve Dexamethasone for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Dexamethasone for the 
enrollee.  
 
Benefits for this drug 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology (81479) provided December 9, 
2021. 
 
You asked the Plan to pay for the laboratory service. You say that please find a copy of all available medical 
records you obtained from the referring provider. The Plan denied your request. The Plan says the services do 
not meet coverage requirements. 
 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. The Plan had confirmed by outreach to the ordering provider listed, 
that the doctor did not order the Genetic testing in this case. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for unlisted molecular pathology (81479) provided December 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve liner cushion for a precautionary helmet. 
 
You asked the Plan to pre-approve liner cushion for a precautionary helmet. You say that it is medically 
necessary for 99+ months for the enrollee to have an adult protective helmet. You state an adult protective 
helmet will provide protection against further head injuries that could ultimately result In death. The Plan 
denied your request. The Plan says your request is not a covered benefit because padding for this helmet is used 
as a precaution and does not treat a medical condition. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is available to the general public and would be helpful even to those who are not sick or injured. 
Therefore, we decided that the Plan does not have to pre-approve liner cushion for a precautionary helmet.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Carboplatin, and Pemetrexed. 
 
You asked the Plan to pre-approve Keytruda, Carboplatin, and Pemetrexed. You say that these drugs are 
needed as part of a chemotherapy regiment. The Plan denied your request. The Plan says medical studies have 
not proven that these drugs are helpful when the enrollee has tried but not had a positive response to another 
anti-PD1 drug. 
 
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, Carboplatin, and 
Pemetrexed. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found 
a diagnosis of metastatic Stage IVA adenocarcinoma of the lung. Treatment with Opdivo and Yervoy was 
started in December 2020. A delayed cycle #11 of treatment was due to begin on March 26, 2022. A positive 
emission tomography (PET) scan done in March 2022 demonstrated a new mildly metabolic lytic lesion in the 
left pedicle of L4 concerning for oligometastatic disease. The National Comprehensive Cancer Network (NCCN) states that if there is progression of adenocarcinoma while on PD-1/PD-L1 inhibitor (as Opdivo), use 
of a PD-1/PD-L1 inhibitor (as Keytruda) is not recommended. The documentation does not support that the 
requested drugs are safe and effective and otherwise reasonable and necessary for this 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 Keytruda, Carboplatin, and Pemetrexed have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Keytruda, Carboplatin, and Pemetrexed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 10, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 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 76705 
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 76705 billed for date of service March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on December 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 pay for the genetic testing services provided on December 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve RFA services. You say that this procedure 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 RFA will be covered after at least 2 MBBs that 
each provide at least a consistent minimum of 80% sustained relief of primary pain.  
 
We looked at the file and Medicare rules. In this case, the documentation does not support that the enrollee has 
had 2 MBBs that each provided a consistent minimum of 80% sustained relief of primary pain. Based on this 
information, we decided that Medicare rules for coverage of RFA services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the facet joint radiofrequency ablation (RFA) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on 
November 16, 2021. 
 
You asked the Plan to pay for the testing services. You say that the codes are payable as billed. The Plan denied 
your request. The Plan says the testing is non-covered. The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation. 
 
We looked at the file and Medicare rules. The medical records do not clearly document the intent for the testing 
to be done. The medical records do not show that the testing was ordered for a specific diagnosis or part of a 
specific treatment plan. There are no records to show that the testing was needed over the standard of care for 
the enrollees condition. Medicare does not cover this testing for screening services. Therefore, we decided that 
the Plan does not have to pay for the cardiovascular risk assessment testing provided on November 16, 2021.
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 requires the interdisciplinary approach 
to care that is offered in the IRF setting. You also say the enrollee wants to regain strength, endurance, and 
functional independence. To reduce the burden of care on the enrollees family and to reduce the risk of 
complications, the IRF admission would be beneficial and would allow the enrollee to return home. The Plan 
denied your request. The Plan says the enrollees needs can be safely met in another setting such as home with 
outpatient therapy, a home health program, or a skilled nursing facility (SNF). The Plan says there is no 
documentation supporting the medical necessity of IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs do not 
indicate the need for an IRF admission. Specifically, the enrollee does not require treatment by multiple 
therapies, including physical therapy and/or occupational therapy, in an intensive rehabilitation therapy 
program. 
 
Our reviewer says the enrollee maintains a need for skilled therapy due to ongoing safety concerns and the 
potential for functional improvement. However, there is no documentation indicating the enrollee meets the 
criteria for IRF admission. Further services can be provided 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service December 
12, 2021. 
 
You asked the Plan to pay for procedure code 99284. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99284 is bundled into payment for code 99285. 
 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 99284 
is a column II code to column I code 99285. 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 99284 billed for date of service December 12, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre (CPT code(s): K0553 and K0554). 
 
You asked the Plan to pre-approve the Freestyle Libre. You say that the Freestyle Libre is necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation does not show that the enrollee is insulin-treated 
with multiple (three or more) injections of insulin a day, or a Medicare covered continuous under the skin 
insulin fusion pump. The notes do not show that the enrollee's insulin treatment plan requires frequent 
adjustment by the enrollee based on testing results. Based on this information, we decided that Medicare rules for coverage of the Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Freestyle Libre (CPT code(s): K0553 and K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive the deductible and coinsurance for an office visit on February 
18, 2022. 
 
You asked the Plan waive the deductible and coinsurance for an office visit on February 18, 2022. You say that 
you had already met your deductible. The Plan denied your request. The Plan says you are responsible for a 
$110 deductible.  
 
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 have a $110 
deductible. The plan also says you must pay a 15% copayment for services obtained from a specialist. 
 
You have been asked to pay $118.23 for an office visit on February 18, 2022. An office visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. At the time this claim was 
processed you had not yet met your deductible. The Plan allowance was $164.89. Your $110 deductible was 
applied ($164.89-$110=$54.89). Your 15% coinsurance was then applied ($54.89x15%=$8.23). You are 
responsible to pay $118.23 for the office visit ($110+$8.23=$118.23).  
 
You have also asked the plan to waive the coinsurance for an electrocardiogram performed on February 18, 
2022. The Plan contract also says that enrollees must pay a 15% coinsurance for in-network, non-radiological 
diagnostic services. You can find this information in Chapter 4, on page 44 of the Plans 2022 EOC. 
 
You have been asked to pay $2.11 for an electrocardiogram performed on February 18, 2022. An electrocardiogram 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plans 
allowance was $14.05. Your coinsurance was applied ($14.05x15%=$2.11). Therefore, your total cost-sharing 
amount is $220.34 ($118.23 for the office visit and $2.11 for the electrocardiogram). 
 
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 the deductible and coinsurance for an office visit on February 18, 2022, or the 
coinsurance for the electrocardiogram performed on February 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional funds over your yearly benefit allowance of 
$500 per ear for hearing aids. 
 
You asked the Plan to pre-approve additional funds over your yearly benefit allowance. You say that hearing 
aids are a necessity, and you have a prescription from the doctor. You also say that you should not have any 
out-of-pocket costs for hearing aids. The Plan denied your request. The Plan says your benefit with the Plan's 
hearing aid vendor allows for $1,000 for hearing aids per year. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only up to the annual allowance of $500 per ear, per year.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of additional funds over your yearly benefit allowance have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional funds over your yearly benefit allowance of $500 per ear for 
hearing aids.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology office visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visits. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there are network providers available. 
 
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 services. Therefore, we decided that 
the Plan does not have to pre-approve oncology office visits to be provided by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme 
 
You asked the Plan to pre-approve Feraheme. 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 Feraheme. 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 iron deficiency anemia with intolerance or inadequate response to oral 
iron replacement. The documentation does not support that the enrollee has tried and failed Infed (iron dextran) 
and Venofer (iron sucrose). The documentation does not support an indication that Infed or Venofer 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a specialist (99205) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit with a specialist. You say that you are afraid your cancer may 
have spread, which would put your health at risk. You also say the soonest appointment with an in-network 
provider is 08/23/2022 and you do not feel comfortable waiting that long when you can get in sooner with the 
OON provider on 08/02/2022. The Plan denied your request. The Plan says you must receive care from a 
network provider. The Plan also says you are scheduled for surgery on 8/23/2022 with the in-network provider. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit with a specialist (99205) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided 
on December 14, 2021. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately 
payable. 
 
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 99233 
is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided on December 14, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cryoablation of breast tumor (0581T) provided on January 
18, 2022. 
 
You asked the Plan to pay for a cryoablation of breast tumor. You say that you have provided medical records 
to support the service billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that an MUE for a HCPCS/CPT code is the 
maximum number of units of service under most circumstances allowable by the same provider for the same enrollee on the same date of service. 
 
We find that CPT code 0581T is not supported because the units of service exceed the code's MUE of 0. Based 
on this information, we decided that Medicare rules for coverage of a cryoablation of breast tumor have not 
been met. Therefore, we decided that the Plan does not have to pay for a cryoablation of breast tumor (0581T) 
provided on January 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs rendered on February 11, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says self-administered drugs are not covered. 
 
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 pay for the self-administered drugs 
rendered on February 11, 2022.