Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and laryngoscopy provided on September 20, 
2022. 
 
You asked the Plan to pay for the outpatient services. You say that you feel the services were an emergency 
due to your condition. The Plan denied your request. The Plan says payment cannot be made to a provider that 
has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Additionally, the record shows that you signed an acknowledgement 
that you would be responsible for the full payment of these services. Therefore, we decided that the Plan does 
not have to pay for the office visit and laryngoscopy provided on September 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says the Medicare guidelines were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
MRI of the lumbar spine is not medically necessary. Our physician reviewer found that the record indicates that 
the enrollee has low back pain with neuralgia and neuritis. The record does not indicate the presence of red flag 
signs or symptoms or the presence of abnormal neurologic findings. The record indicates that plain films and 
physical therapy have been ordered. The requested service is not medically necessary and reasonable for the 
diagnosis and treatment for the enrollee's clinical condition at this time. 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an inclisiran injection provided on 
October 12, 2022. 
 
You asked the Plan to reduce the coinsurance for an inclisiran injection. You say that you cannot afford the 
cost sharing amount. 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 20% 
coinsurance for Medicare Part B chemotherapy drugs and other Part B drugs. 
 
You have been asked to pay 20% coinsurance for an inclisiran injection. This item/service falls within the 
Medicare Part B chemotherapy drugs and other Part B 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 reduce the coinsurance for an inclisiran injection provided on October 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this will increase likelihood of compliance and 
efficacy of treatment. The Plan denied your request. The Plan says a ventilator is not covered by Medicare for 
this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, 
shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for code J3490 billed for date of service July 12, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the code is 
included in the global surgery period of code 27096. 
 
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, the CPT Code Manual definition of code J3490 is unclassified drugs. We find that CPT code J3490 
is supported in the medical record. The code at issue was submitted with a national drug code that corresponds 
with the drug documented in the medical records. Code J3490 is not an evaluation and management service. 
The drug is separately payable. The Plan has not provided a Medicare rule that would indicate the drug should 
be included in the global surgery package. Based on this information, we decided that Medicare rules for 
coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for code J3490 
billed for date of service July 12, 2022.  
 
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 an automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (K0606) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the wireless cardiac defibrillator. You say that you are filing this appeal 
because your doctor ordered you for a life vest. When you were in the hospital, they came into your room and 
fitted you for the vest and no one told you that it wasn't going to be covered. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) to be 
provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM) and related supplies. You say that you 
have a problem with your blood sugar dropping too low, especially at night while you sleep. You say that you 
have had to go to the emergency room because of the problem. You say that this is a life-or-death matter. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous 
glucose monitor (CGM) and related supplies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor (CGM) and related supplies.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 9, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre Kit 2 sensor. You say that this is a continuation of care. 
You say that the enrollee has complex regional pain syndrome and that taking blood sugars by fingertip leads 
to tremendous and increased pain. You say that the enrollee needs the ability to measure his blood sugars using 
the Freestyle Libre. The Plan denied your request. The Plan says a continuous glucose monitor is not covered 
under Medicare if the enrollee is not on insulin. 
 
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 a 
Freestyle Libre Kit 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre Kit 2 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis - adult (D1110), prophylaxis - adult 
(D0120), adjunctive procedure (D9999) provided on August 17, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you had a previous date of services and 
paid out-of-pocket to the provider for the services received. You also say that you advised the Plan paid the 
provider but you were not reimbursed and it was applied to your account with the providers office.  The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider. 
 
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. 
 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 more for prophylaxis - adult (D1110), prophylaxis - 
adult (D0120), adjunctive procedure (D9999) provided on August 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skyrizi. 
 
You asked the Plan to pre-approve Skyrizi. You say that the enrollee started with infusions and is now past due 
for their on-body injector. The Plan denied your request. The Plan says Skyrizi cartridge is for subcutaneous 
use with the on-body injector that is self-administered at home every 8 weeks and can be used long term. The 
Plan also says Skyrizi is a benefit exclusion under the enrollee's Medicare Advantage (MA) plan. 
 
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 Skyrizi.  
 
  Benefits for Skyrizi 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam with photos provided on 
October 12, 2022. 
 
You asked the Plan to waive the copayment for the eye exam with photos. You say that you should not have a 
$20 copayment for pictures taken of your eyes. You say there was no mention of 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $20 copayment for each Medicare-covered eye exam (diagnosis and treatment for disease and 
conditions of the eye).  
 
The enrollee has been asked to pay a $20 copayment for the eye exam with photos. This item/service falls 
within vision care benefit category. The record shows the eye exam with photos is considered an outpatient 
physician service.  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 eye exam with photos provided on October 
12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 reader. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 reader. You say that you have met all the criteria needed 
to be approved for the continued use of the FreeStyle Libre 2. The Plan denied your request. The Plan says a 
continuous glucose monitor is not covered under Medicare if you are not on insulin. 
 
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 you do not use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 2 reader 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 
reader.
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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria 
for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: 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 you need rehabilitation to assist in returning to your 
prior level of functioning. The Plan denied your request. The Plan says the enrollee's condition does not meet 
the requirements for an IRF admission. 
 
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 require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that you are appealing this denial. The Plan denied your 
request. The Plan says Injectafer 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 Injectafer. Our reviewer says that the 
enrollee does not meet criteria for use of Injectafer. Our physician reviewer found Injectafer is not Food & 
Drug Administration (FDA) approved for the enrollee's diagnosis. This use is not supported by one of the 
major drug compendia or by clinical research appearing in a Medicare-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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Injectafer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the placement of amniotic membranes and 
the destruction of a localized retina lesion provided on November 7, 2022, and November 11, 2022.  
 
You asked the Plan to waive the coinsurance for the surgical services. You say that the surgical costs should 
have been covered in full. 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 40% 
coinsurance for out-of-network surgery services.  
 
You have been asked to pay a total of $5,858.80, which is 40% coinsurance of the allowed amount for the 
surgical services. 
 Date of Service Allowed Amount 40% Coinsurance 
November 8, 2022 $8,375.34 $3,350.14 
November 8, 2022 $4,187.66 $1,675.06 
November 11, 2022 $2,084.01 $833.60 
Total  $5,858.80 
 
These services fall within the outpatient surgery 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 the placement of amniotic membranes and the destruction of a localized retina lesion provided 
on November 7, 2022, and November 11, 2022.