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

 
We decided that the Plan does not have to pre-approve a Minuteman procedure. 
 
You asked the Plan to pre-approve a Minuteman procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Minuteman procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Therefore, the requested Minuteman 
procedure at L4-5, in this case, is not medically reasonable or necessary. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman procedure.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a Tempus Origin genetic test billed for date of service December 6, 
2021. 
 
You asked the Plan to pay for genetic testing. You say that you have provided records to support the service 
billed. The Plan denied your request. The Plan says that rules for payment have not been met because the DOS 
must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. The rules say that, with certain exceptions, the DOS of the test/service 
must be the date the specimen was collected. One such exception is for a molecular pathology test performed 
by a laboratory other than a blood bank or center that satisfies the criteria listed in the Medicare rules section. 
The rules also 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. 
 
We looked at the file and Medicare rules. In this case, the service at issue is a molecular pathology test 
performed by a laboratory other than a blood bank or center. The Plan has not asserted nor documented that the 
specimen was not collected during an outpatient hospital encounter. It is the Plans responsibility to 
substantiate its denial. In this case, it appears that the date of service in this case is the date the test was 
performed. Based on this information, we decided that Medicare rules for coverage of genetic testing have been 
met. Therefore, we decided that the Plan has to pay for a Tempus Origin genetic test billed for date of service 
December 6, 2021.  
 
  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 pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system (E2300). You say that the requested power 
seat elevation system is medically necessary. The Plan denied your request. The Plan says a power seat 
elevation system (E2300) is statutorily non-covered by Medicare and the Plan. 
 
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 specifically excludes coverage of power seat elevation 
systems coded as E2300. Therefore, we decided that the Plan does not have to pre-approve a power seat 
elevation system (E2300).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation. 
 
You asked the Plan to pre-approve routine transportation. You say that the services are necessary. The Plan 
denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on May 
2, 2022. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you would like the 
copayment to be reconsidered. You feel the care provided was un-necessarily and a neglectful accident in the 
hospital parking lot. The Plan denied your request. The Plan says the copayment 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 a $225 
copayment for Medicare-covered ambulance services (each way).  
 
You have been asked to pay a $225 copayment for ambulance transportation. Ambulance transportation falls 
within the Ambulance Services 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 
ambulance transportation provided on May 2, 2022.  
 Your complaint about the care provided being un-necessary and a neglectful accident occurring in the hospital 
parking lot is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 28, 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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, we find that the testing described by the billed code 
is considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on March 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve a polysomnography. The Plan denied your request. The Plan says in-
network options are 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 a 
polysomnography to be provided by an out-of-network provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vein treatment. 
 
You asked the Plan to pre-approve vein treatment. 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 follows Medicare rules. Medicare rules say that invasive procedures will be considered medically 
reasonable and necessary if the patient meets the criteria as outlined in this LCD, and the intervention is 
addressed and supported in the plan of care, for a 90 day episode of care, that includes a specific treatment plan 
determined by the assessment and evaluation of the lower extremity venous incompetence. 
 
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 vein treatment. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found as there is no documentation that the 
enrollee is having lifestyle limiting symptoms despite the use of compression stockings, there is no indication 
for further treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vein treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vein treatment.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria. 
 
You asked the Plan to pre-approve Simponi Aria. You say that the requested Simponi Aria is medically 
necessary. The Plan denied your request. The Plan says the enrollee must try and fail Humira, Enbrel, or 
Xeljanz. 
 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 Simponi Aria. Our reviewer says that 
the Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has psoriatic arthropathy. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the requested Aranesp is medically necessary. The 
Plan denied your request. The Plan says the requested Aranesp is not medically necessary. 
 
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 Aranesp. Our reviewer says that the 
requested Aranesp is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of folate and B12 deficiency macrocytic anemia. The record provided is insufficient to 
support a diagnosis of chronic renal disease and does not contain the results of iron studies. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation.  The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig provided on March 22, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the wig. You say that your cancer center has used this provider before, and you 
would like to be reimbursed for this item. The Plan denied your request. The Plan says you did not use a 
network provider for this item. 
 
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 provider in this case is not a network provider with the Plan. 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 the wig provided on March 22, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long-term EEG procedures provided on May 20, 2021. 
 
You asked the Plan to pay for long-term EEG procedures. The Plan denied your request. The Plan says long-
term EEG procedures are 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 pay for long-term EEG procedures. Our reviewer 
says that long-term EEG procedures are not considered medically reasonable and necessary. Our physician 
reviewer found that the diagnostic testing evaluated the enrollees symptoms of one episode of sudden loss of 
consciousness. Ambulatory monitoring, however, is not necessary to evaluate most seizures, which are usually 
readily diagnosed by routine EEG studies and history. Medicare anticipates that many of these outpatient 
studies will not provide the diagnosis within the first 24hours but expects that 48 hours of monitoring will be diagnostic in most circumstances. The clinical value and effectiveness of a 72-hour ambulatory video EEG in 
the setting of an initial diagnostic testing for possible seizure activity is not the standard of care. The review has 
determined that long-term EEG procedures at issue in this case medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of long-term EEG procedures have not been met. Therefore, we decided that the 
Plan does not have to pay for long-term EEG procedures (CPT 95724) provided on May 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 10, 2022. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on May 10, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Victoza. 
 
You asked the Plan to pre-approve Victoza. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Victoza is not covered under your Medicare Part B benefit. 
 
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 Victoza.  
 
Benefits for Victoza 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on August 20, 
2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you feel you should not have 
to pay for the visit. You say the urgent care provider suggested you go to the emergency room because you 
needed a scan done and they were not able do one. The Plan denied your request. The Plan says the copayment 
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 a $45 
copayment per visit for covered services to a medical facility or urgent care center.  
 
You have been asked to pay a $45 copayment for an urgent care visit. An urgent care visit falls within the 
Urgently Needed Services 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 urgent 
care visit provided on August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ComforTouch lancets. 
 
You asked the Plan to pre-approve these services. You say that  The Plan denied your request. The Plan says 
the services are available from the preferred providers. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file and Medicare rules. The requested items are from a non-preferred provider. The services 
are available from one of the Plans preferred providers. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve ComforTouch lancets.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested Botox is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Botox is only covered for certain indications. 
 
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 Botox. Our reviewer says that the 
documentation does not support that the requested Botox is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of gastroparesis. Gastroparesis is not a medically-accepted 
indication for use of Botox as defined by Medicare criteria and the LCD. Therefore, the enrollee does not meet 
criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for unlisted ambulance service (code A0999) provided on  
December 3, 2021. 
 
You asked the Plan to pay for the unlisted ambulance service. You say that you called for emergency and the 
Fire Department and ambulance came to your apartment. You say that you were unable to stand on your own 
on your right side from your waist all the way down and you were unable to walk or carry any 
weight never had a problem like this. You say that the paramedic checked vitals and instructed the ambulance 
to take you to the hospital. The Plan denied your request. The Plan says that the ambulance benefit is a 
transport only benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a rule to support denial of an unlisted ambulance 
service. Therefore, we decided that the Plan has to pay for unlisted ambulance service (code A0999) provided 
on December 3, 2021.  
 
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.