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

 
We decided that the Plan does not have to pre-approve arm lift surgery (excision of excessive skin and 
subcutaneous tissue). 
 
You asked the Plan to pre-approve arm lift surgery. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that excision of excessive skin and subcutaneous tissue 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 arm lift surgery. Our reviewer says that 
the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the documentation shows that you had weight loss surgery which resulted in weight 
loss of 200 pounds. You now have persistent skin and subcutaneous tissue of the bilateral upper arms which 
causes discomfort. The physical exam documented significant excess loose skin of the upper arms, to a point 
that makes clothing difficult to fit. This is causing musculoskeletal problems with your shoulders and neck. 
You do not have lymphedema of the upper extremities. Reconstructive surgery is performed to restore and 
improve function and correct any deformities or abnormal structures of the body that have been caused by 
congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The case file does not 
contain documentation of congenital defects, developmental abnormalities, trauma, infection, tumors or 
disease. Therefore, you do 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 arm lift surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arm lift surgery (excision of excessive skin and subcutaneous tissue).
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 this is medically necessary. The Plan denied your 
request. The Plan says the requested 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 intensive therapy is not reasonable or necessary for the enrollee. He does not 
have capacity for intensive rehabilitation. Chemotherapy and immunotherapy will likely limit his capacity further. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for pulse oximetry provided on June 15, 2022. 
 
You asked the Plan to reduce the copayment for pulse oximetry. You say that you should only be responsible to 
pay $30. 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 $100 
copayment for diagnostic procedures and tests performed in an in-network outpatient hospital setting.  
 
 
 
 
 
 
 You have been asked to pay $45 for the pulse oximetry, which is less than the standard $100 copayment. Of 
note, this service was billed by the hospital, not the physician. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the 
copayment for the pulse oximetry provided on June 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo (J9299). 
 
You asked the Plan to pre-approve Opdivo. You say that the enrollee is not a candidate for Pemtrexed due to 
functional status and age. The Plan denied your request. The Plan says the clinical value and effectiveness of 
Opdivo as a first line chemotherapy in the setting of advanced non-small cell lung cancer have 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 the 
enrollee does not meet the criteria for coverage for Opdivo. Our physician reviewer found the requested use of 
Opdivo is not FDA-approved for the enrollees diagnosis. The use is not supported by one of the major drug 
compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved 
medical journal. Our reviewer found that the use is listed as not indicated, not supported or not recommended 
in the compendia. Our physician reviewer also found that the compendia demands programmed cell death 
ligand 1 (PD-L1) be positive to approve Opdivo as a first line 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 Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo (J9299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that the requested item is medically 
necessary. The Plan denied your request. The Plan says other brands are not covered unless there is an 
explanation that supports medical necessity for a non-covered brand. The enrollees preference is not sufficient 
to justify coverage for a non-covered 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 Plan will not cover other brands unless your provider tells us it is 
medically necessary. The records show the provider did not submit an explanation on why the enrollee cannot 
use the preferred monitor.  Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter. 
 
You asked the Plan to pre-approve a Dexcom G6 transmitter. You say that the requested item is medically 
necessary. The Plan denied your request. The Plan says other brands are not covered unless there is an 
explanation that supports medical necessity for a non-covered brand. The enrollees preference is not sufficient 
to justify coverage for a non-covered 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 Plan will not cover other brands unless your provider tells us it is 
medically necessary. The records show the provider did not submit an explanation on why the enrollee cannot 
use the preferred transmitter. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 transmitter have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 transmitter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on May 18, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that this was your annual wellness visit 
and you should not be responsible to pay a 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 $350 
copayment for Medicare-covered outpatient hospital surgery services and a $20 copayment for all other 
Medicare-covered outpatient hospital services.  
 
 
 
 
 
 You have been asked to pay $20 for an office visit. This item/service falls within the outpatient hospital 
services benefit category. The records show conditions were discussed that are outside the scope of an annual 
wellness visit.  This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for an office visit on May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Radiation therapy treatments provided 
from March 21, 2022, to April 29, 2022 
 
You asked the Plan to waive the coinsurance for Radiation therapy treatments. You say that you feel that the 
coinsurance should be lowered, if the plan can have the allowed amount lowered, you should be able to as well. 
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% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $3340.87 coinsurance for radiation therapy treatments. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the coinsurance for Radiation therapy treatments 
provided from March 21, 2022, to April 29, 2022
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multi-level lumbar fusion surgery. 
 
You asked the Plan to pre-approve multi-level lumbar fusion surgery. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the enrollee has not 
adequately demonstrated conservative therapy. 
 
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 multi-level lumbar fusion surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 71-year-old female being treated for osteoporosis; 
anemia; peripheral vascular disease; kyphosis of the thoracic region; fusion of spine of the lumbar region; 
fusion of the spine, lumbosacral region; other intervertebral disc degeneration of the lumbar spine; spinal 
instabilities, thoracic region; age-related osteoporosis without current pathological. They presented with 
continued issues with balance and is using objects in her home to get around.  
 
In this case, detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. Moreover, the provided diagnostic imaging studies 
did not corroborate pathology at the requested surgical levels. Radiographic instability is not demonstrated at 
any level from T11-L2 and detailed documentation is not evident regarding potential impending/inevitable 
temporary intra-operative instability. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested multi-level lumbar fusion surgery at T11-12, T12-L1, and L1-2, 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 multi-level lumbar fusion surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve multi-level lumbar fusion surgery.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical records indicates that the enrollee is pre-diabetic. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical appropriateness and necessity of carrying out a radionuclide stress test. The 
patient has a history of hypertension and is asymptomatic. The enrollee's pre-test probability for an abnormal 
test is low and there is no documentation that the electrocardiogram shows an uninterpretable pattern. There is 
no evidence provided that would support the need for radionuclide stress testing. In summary, there is 
insufficient documentation to support the medical necessity for the requested cardiac stress testing in this 
patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve myocardial perfusion imaging for the enrollee.
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 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 you are chronically deconditioned and able to transfer and walk modified 
independence. You do not require intensive rehabilitation. You can improve endurance with a repetitive 
exercise program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88112 billed for date of service December 2, 
2021. 
 
You asked the Plan to pay for procedure code 88112. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 88112 is bundled into 
payment for code 88173. 
 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 88112 
is a column II code to column I code 88173. 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 88112 billed for date of service December 2, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy provided on May 20, 2022. 
 
You asked the Plan to waive the copayment for a biopsy. You say that this was the enrollee's first colonoscopy, 
and they should not have to pay this. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $325 copayment for same-day outpatient surgery in an outpatient hospital facility.  
 
The enrollee has been asked to pay a $325 copayment for a biopsy. This item/service falls within the outpatient 
hospital services benefit category. This means that the enrollee has been asked to pay the correct amount based 
on the contract with the Plan.  This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for the biopsy provided on May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Otolaryngologist visit (99203, 99213) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the Otolaryngologist visit. You say that this service is 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 an 
Otolaryngologist visit (99203, 99213) 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 pre-approve Percutaneous Electrical Nerve Stimulation (PENS) 
(64555). 
 
You asked the Plan to pre-approve PENS. You say that you want to appeal this. The Plan denied your request. 
The Plan says the requested service is not covered for the enrollee's condition. 
 
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 PENS. Our reviewer says that the 
requested PENS is not considered medically reasonable and necessary in this case. Our physician reviewer 
found more research is needed to show safety and efficacy. The requested service is considered experimental. 
Therefore, the reviewer found that the requested service 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 PENS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Percutaneous Electrical Nerve Stimulation (PENS) (64555).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug (A9270) provided on May 12, 
2022, in an outpatient setting. 
 
You asked the Plan to pay for the self-administered drug. You say that $94.99 is a lot of money for a few puffs 
on an inhaler. You say that no one told you to bring an inhaler. You also say that you went to the hospital for a 
test. The Plan denied your request. The Plan says the self-administered drug is not covered under Medicare 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 pay for the self-administered drug 
(A9270) provided on May 12, 2022, in an outpatient setting.