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

 
We decided that the Plan does not have to pre-approve Trazimera, Dexamethasone sodium phosphate, and 
Diphenhydramine HCL. 
 
You asked the Plan to pre-approve Trazimera, Dexamethasone sodium phosphate, and Diphenhydramine HCL. 
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 Medicare may pay for unlabeled uses for FDA-
approved 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 Trazimera, Dexamethasone sodium 
phosphate, and Diphenhydramine HCL. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found unlike in breast and gastric cancer, in NSCLC HER2 protein overexpression is not 
validated to be a biomarker predictive of clinical response to HER2-targeted agents. The use of the requested 
drugs are not supported by one of the major drug compendia or by clinical research that appears in a 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 Trazimera, Dexamethasone sodium phosphate, and Diphenhydramine HCL have not been met. Therefore, we decided that the Plan does not have to pre-approve Trazimera, 
Dexamethasone sodium phosphate, and Diphenhydramine HCL.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening (71271). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested 
service. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
 We reviewed the case file and Medicare rules. Based on this information, we find that you do not meet 
Medicare criteria for coverage of the requested service. Specifically, the rules say that Medicare covers one 
annual LDCT scan for lung cancer screening for enrollees who are between 55 and 77 years of age. Therefore, 
we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening (71271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to restore your over-the-counter (OTC) allowance from the third 
quarter. 
 
You asked the Plan to restore your over-the-counter (OTC) allowance from the third quarter. You say that you 
want your $100 allowance from the third quarter OTC benefit restored as you did not hit the submit button at 
the end of the order page. You also say that you did not see the button. The Plan denied your request. The Plan 
says according to your EOC, quarterly allowances cannot be carried over to another quarter. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and your over-
the-counter (OTC) allowance from the third quarter is an OTC item. Therefore, we decided that the Plan does 
not have to restore your over-the-counter (OTC) allowance from the third quarter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve quantitative calcium scoring. 
 
You asked the Plan to pre-approve quantitative calcium scoring. 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. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of quantitative calcium scoring have not been met. Therefore, we decided that the Plan does not have 
to pre-approve quantitative calcium scoring.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips to 
get to your doctor appointments. The Plan denied your request. The Plan says the requested complimentary 
non-emergent transportation benefits, above the allotted 100 one-way trips per calendar year, are excluded 
from coverage. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 100 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation as of November 7, 
2022. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional one-way trips. 
 
You asked the Plan to pre-approve additional one-way trips. You say that you need transportation Monday 
through Friday to visit this facility for your depression. You also say that you have a lot of doctor's 
appointments pending because you do not have transportation. The Plan denied your request. The Plan says as 
of September 7, 2022, you have used or scheduled 100 one-way trips. Your request for a 101st trip is not a 
covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 one-way trips per year.   
We looked at your request, the records in the case file, and the rules. The rules say that you have up to 100 one-
way trips. The record shows that this benefit was exhausted on September 7, 2022. Based on this information, 
we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve additional one-way trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visits. You say that you have submitted records for this denial, as a 
gap exception for a re-evaluation for squamous cell carcinoma. The Plan denied your request. The Plan says the 
enrollee does not have out-of-network coverage. The Plan also says they have confirmed that there are two 
participating providers that can provide the requested service. 
 
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 
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 waive the copayment for a methylprednisolone injection (J1040) 
provided on September 8, 2022. 
 
You asked the Plan to waive the copayment for the methylprednisolone injection. You say that the services 
should be covered as you disagree with the denial. The Plan denied your request. The Plan says this cost 
sharing was charged 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). Your contract with the Plan clearly says that you must pay a $20 
copayment for Medicare Part B prescription drugs.  
 
 
  You have been asked to pay a $10.44 copayment for the methylprednisolone injection, which is less than the 
standard $50. This item/service falls 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 for a methylprednisolone injection (J1040) provided on 
September 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre continuous glucose monitor and 
supplies. 
 
You asked the Plan to pre-approve FreeStyle Libre continuous glucose monitor and supplies. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for the 
requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
FreeStyle Libre continuous glucose monitor and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve FreeStyle Libre continuous glucose monitor and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation. 
 
You asked the Plan to pre-approve non-emergency transportation. You say that you need extra trips due to the 
arthritis in both of your knees. The Plan denied your request. The Plan says the 2022 EOC clearly states 100 
one-way trips per calendar year, and the 101st and beyond is not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visit (99204) and the chiropractic 
manipulative treatments (98941 x 3) provided from March 21, 2022, through July 19, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services are 
not payable as medical records were not provided to support the medical necessity of these services.  
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  Additionally, Medicare rules say that the only covered chiropractic service is 
manual manipulation of the spine to correct a subluxation.  
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of these services have been met.   
Specifically, the medical records were not provided in this case to support the medical necessity of the 
chiropractic manipulative treatment services rendered despite the Plans requests for these records. 
Additionally, Medicare rules say that the only covered chiropractic service is manual manipulation of the spine 
to correct a subluxation. Therefore, we decided that the Plan does not have to issue reimbursement for the 
office visit (99204) and the chiropractic manipulative treatments (98941 x 3) provided from March 21, 2022, 
through July 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiography test provided on May 
06, 2022. 
 
You asked the Plan to waive the copayment for an echocardiography test. You say that you needed this test and 
cannot pay this copayment. The Plan denied your request. The Plan says this cost sharing was charged 
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). Your contract with the Plan clearly says that you must pay a $130 
copayment for Other outpatient diagnostic tests - Radiological diagnostic services, not including x-rays. 
 
You have been asked to pay a $130 copayment for an echocardiography test. This item/service falls within the 
Other outpatient diagnostic tests - Radiological diagnostic services, not including x-rays 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 echocardiography test provided on May 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic treatment. 
 
You asked the Plan to pre-approve chiropractic treatment. You say that chiropractic treatment is medically 
necessary. The Plan denied your request. The Plan says the chiropractic services are only covered if they 
require manual manipulation of the spine to correct subluxation. There is no indication in the provided clinical 
notes that the member has subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 chiropractic treatment Our reviewer 
says that chiropractic treatment is not medically necessary. Our physician reviewer found in this case; the 
record indicates that you have lumbar radiculopathy. The record does not contain a physical examination upon 
which the order was based. The provided record does not indicate that the enrollee has subluxation as defined 
by the coverage rules. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic treatment.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a wheelchair component (battery) (K0108). 
 
You asked the Plan to pre-approve a replacement battery. You say that the enrollee needs this. The Plan denied 
your request. The Plan says that this request was made with an incorrect procedure code, K0108. The Plan also 
says that this cannot be covered. 
 
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. Specifically, the file clearly shows that it is a battery being requested. The denial 
based on the procedure code alone is not appropriate for a prospective request. Therefore, we decided that the 
Plan has to pre-approve a wheelchair component (battery) (K0108).  
 
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: 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy for tooth 18 and 19. 
 
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 the services are not covered. 
 
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 pre-approve 
gingivectomy for tooth 18 and 19.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that you disagree with the denial for an 
Intracept procedure. The Plan denied your request. The Plan says the requested procedure is 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kanjinti. 
 
You asked the Plan to pre-approve Kanjinti. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Kanjinti. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of both metastatic non-small cell lung cancer (NSCLC) and/or 
ethmoid sinus carcinoma. The Food and Drug Administration has not stated that the requested drug regimen is indicated for either of the enrollee's condition. The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug for either of the enrollee's conditions. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kanjinti have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Kanjinti.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for ambulance transport/treatment provided on 
May 17, 2022. 
 
You asked the Plan to waive the cost share for ambulance services. You say that you were taken to the hospital 
and admitted; therefore, you should not be responsible for this bill. The Plan denied your request. The Plan says 
since there is not contract between the advanced life support (ALS) provider and the basic life support (BLS) 
provider then no payment can be made to the ALS and therefore it is the members responsibility. 
  The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to waive the cost share 
for ambulance transport/treatment provided on May 17, 2022.