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

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on June 
7, 2021. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on June 7, 2021. The total allowed amount is $24.48 and 20% of that is 
$4.90.  
 
You have been asked to pay the total coinsurance amount of $4.90 for a Medicare Part B drug. A Medicare Part 
B drug 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 coinsurance for a Medicare Part B drug provided on June 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 5, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on August 17, 2021. 
 
You asked the Plan to pay for the services provided. You say that you were compliant with regulations for 
billing. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The claim billed a place of service as an independent laboratory. If an independent lab bills for services, the 
place where the sample was taken is reported as the place of service. The records do not show that the 
enrollees sample was obtained at the independent laboratory. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing provided on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on July 28, 2021. 
 
You asked the Plan to pay for the services provided. You say that you were compliant with regulations for 
billing. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The claim billed a place of service as 81, an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the enrollees sample was obtained at the independent laboratory. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the Guardant360 testing provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor. 
 
You asked the Plan to pre-approve the Dexcom G6 continuous glucose monitor. You say that the Dexcom G6 
is medically necessary. The Plan denied your request. The Plan says this brand of continuous glucose monitor 
is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The records show no medical reason why the plan preferred brand 
would not meet the enrollee's needs. Based on this information, we decided that Medicare rules for coverage of 
the Dexcom G6 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dexcom G6 continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued inpatient psychiatric services. You say that an inpatient 
psychiatric stay is necessary and no less restrictive setting is appropriate during this time with significant 
regression anticipated without continuity of care. You say that the enrollee failed outpatient psychiatric 
treatment, which is what caused her to require 24-hour professional observation and care in an inpatient 
psychiatric setting. You say that the enrollee is entitled to this continued treatment and care. The Plan denied 
your request. The Plan says inpatient psychiatric care is not medically necessary. The Plan says that the 
enrollee's psychiatric condition can be treated at a lower level of care, such as outpatient treatment. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric services. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee 
was admitted to the acute inpatient psychiatric hospitalization on February 23, 2022, with Major 
Neurocognitive Disorder, Unspecified with Behavioral Disturbance. Based upon review the records provided it 
was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did 
not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. The enrollee did not 
show any abnormal behaviors or any symptoms which would require acute treatment. It did not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care beyond the dates in question.  It does not appear that the services requested are 
reasonably expected to improve the enrollees condition or for the purpose of diagnosis beyond the date in 
question. The enrollee was not showing any aggressive behaviors, or any treatment required for acute threats of 
safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ropinirole for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this drug 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 Ropinirole 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on August 27, 2021. 
 You asked the Plan to pay for therapeutic exercises. You say that these services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the therapy 
services were being rendered. The incident-to requirements have not been met in this case. Based on this 
information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on August 
27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 
26, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this was an annual 
pelvic exam and you never had copayments before. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each specialist visit.  
 
The file shows that you had additional services provided at your visit. Therefore, you have been asked to pay a 
$50 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a specialist office visit provided on October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig provided on September 25, 2021. 
 
You asked the Plan to pay for the wig. You say that the item should be covered. The Plan denied your request. 
The Plan says this item is not covered for your diagnosis. 
 
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 wigs are covered up to 
$500 per a calendar year for members who experience hair loss due to treatment of cancer. 
 
You have been asked to pay the full cost of the wig. There is no indication that you are requesting this item for 
hair loss due to the treatment for cancer, and therefore, this cost share does not apply. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to pay for the wig provided on September 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve SI joint RFA. You say that the enrollee has had several SI joint injections 
over the years and has received great short-term relief from them. The Plan denied your request. The Plan says 
the denial of authorization for this service is correct, because this is experimental/investigational. 
 
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 SI joint RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is considered experimental/investigational because of the wide variation in 
efficacy in the peer-reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Opdivo for the enrollee. 
 
You asked the Plan to pre-approve Opdivo. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that that the clinical value and effectiveness of Opdivo as subsequent 
monotherapy treatment in the setting of esophageal adenocarcinoma has not been demonstrated in the peer-
reviewed literature. 
 
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 Opdivo. Our reviewer says that Opdivo 
is medically reasonable and necessary. Opdivo is not FDA-approved for the enrollees diagnosis as there is as 
no prior fluorouracil based treatment. The use of Opdivo is supported by one of the major drug compendia or 
by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Per 
the NCCN Guidelines alternate combinations and schedules of cytotoxics based on the availability of the 
agents, practice preferences, and contraindications are permitted. Opdivo is also supported by phase 3 data. Our 
physician reviewer found that the enrollee's condition meets criteria for coverage of Opdivo. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have been met. Therefore, we decided that the Plan has to pre-approve 
Opdivo for the enrollee.  
 
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 pay for the catheters provided on May 26, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee is receiving a 3-month supply. 
The Plan denied your request. The Plan says no separate payment is made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. We find that CPT code 4352 is a bundled code. When these services are 
covered, payment for them is subsumed by the payment for the services to which they are incident. Based on 
this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the catheters provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment (98940, 98941) provided 
on October 1, 2021, by an out-of-network (OON) provider 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that you did not know prior 
authorization was needed before treating. You also say you thought you were in network. The Plan denied your 
request. The Plan says the rendering provider is a non-participating provider and there is no referring provider 
involved in these services. The Plan also says that they did not authorize any services for this 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment (98940, 
98941) provided on October 1, 2021, by an out-of-network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on September 23, 
2021. 
 You asked the Plan to pay for therapeutic exercises. You say that these services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapist. There is no indication that the Nurse Practitioner was present on site while the therapy services were 
being rendered. The incident-to requirements have not been met in this case. Based on this information, we 
decided that Medicare rules for coverage of therapeutic exercises have not been met. Therefore, we decided 
that the Plan does not have to pay for therapeutic exercises (97110) provided on September 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services provided on August 5, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
are not eligible for separate reimbursement. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
 
 
 The file shows that the services at issue were provided by a surgical first assistant. We looked at the file and the 
rules. The record does not show that the provider of the surgical assistant service is a physician, PA, NP, or 
CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant services 
provided on August 5, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. Your rehab needs can be 
met at a lower intensity setting such as at home with therapy. 
 
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 Injectafer for the enrollee. 
 
You asked the Plan to pre-approve Injectafer. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that there is no indication our preferred drugs would likely be less 
effective, and/or cause adverse effects for the member. 
 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 Injectafer. Our reviewer says that 
Injectafer is not medically reasonable and necessary. The Plan requires a trial of Infed (iron dextran) and 
Venofer (iron sucrose) before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drugs. There is no documentation provided indicating that the plan's required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the 
enrollee's condition does not meet step therapy criteria for Injectafer 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer for the enrollee.