Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 additional trips. 
 
You asked the Plan to pre-approve 30 additional trips. You say that you are in critical need of additional 
transportation for medical consult visits. The Plan denied your request. The Plan says you have used 60 of the 
allowed 60 trips, and an additional 30 trips would exceed your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 60 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 30 additional trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that there is no phase 
III trial data available for this drug for the enrollee's diagnosis. The STAMP trial is underway. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional non-emergency transportation. You say that you need more rides 
because you have dialysis three times per week. The Plan denied your request. The Plan says your plan benefit 
for this service is exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure codes 58551, 58661) provided 
to the enrollee on June 1, 2022. 
 
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 the removal of the fallopian tubes is included in CPT 58552. 
 
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 58661 is "Laparoscopy, surgical; with removal of adnexal 
structures (partial or total oophorectomy and/or salpingectomy). 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the denied code is not supported 
in the medical records. CPT 58552 includes the removal of either/or tubes and/or ovaries. 
 
We looked at this coder'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 pay for surgical services (procedure codes 58551, 58661) provided to the enrollee on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on August 1, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that your doctor felt it was necessary to perform the 
refraction due to your age. The Plan denied your request. The Plan says this service is not a covered benefit 
since it was performed with a medical diagnosis. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers this service when it is performed during a routine exam. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you received a medical exam for 
the diagnosis of Dry eye syndrome of bilateral lacrimal glands. Based on this information, we decided that the 
Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not 
have to pay for the eye refraction (92015) provided on August 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on March 25, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. The Plan 
denied your request. The Plan says this denial is being upheld due to the provider not submitting referring 
provider records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the non-emergency ambulance 
transportation and ground mileage have been met. Medical records and/or a trip report were not provided for 
this case. The record shows that the Plan made multiple attempts to obtain this information, but it was not 
received. Without these records, we are unable to determine if the provided service was medically necessary 
and meets the criteria for coverage. Therefore, we decided that the Plan does not have to pay for the non-
emergency ambulance transportation (A0428) and ground mileage (A0425) provided on March 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment provided from January 3, 
2022 to May 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medication assisted treatment. You say that you believe this treatment should 
be covered by the Plan. The Plan denied your request. The Plan says the requested care was not prior 
authorized, nor was it urgent/emergent. 
 
 
 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 the medication assisted treatment provided from 
January 3, 2022 to May 30, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Yervoy (ipilimumab). 
 
You asked the Plan to pre-approve the requested use of Yervoy. You say that it is felt that this would be a 
beneficial treatment. The Plan denied your request. The Plan says there is no support for this treatment. 
 
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 the requested use of Yervoy. Our 
reviewer says that the requested use of Yervoy is not shown to be medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a diagnosis of uterine sarcoma. Yervoy is not FDA-
approved for this condition. The use is also not supported by one of the major drug compendia or by clinical 
research that appears 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 the requested use of Yervoy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve treatment with Yervoy (ipilimumab).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271) to be used in combination with 
pemetrexed (J9305), carboplatin (J9045), dexamethasone (J1100), and diphenhydramine (J1200). 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drugs. Our reviewer says that the 
requested drug regimen is not medically reasonable or necessary. Our physician reviewer found that there is not 
enough information regarding pathology of right upper lobe, PDL1, and diver mutations. This request is not 
supported by the major compendia or the current 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 the drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271) to be used in combination with pemetrexed (J9305), carboplatin (J9045), 
dexamethasone (J1100), and diphenhydramine (J1200).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours of in-home support. 
 
You asked the Plan to pre-approve additional hours of in-home support. You say that with additional hours you 
will receive assistance for basic daily needs. You also say that without the assistance, you are often confined to 
your bed. The Plan denied your request. The Plan says this request for more than 60 hours of in-home support 
services is not covered. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 
 
 We looked at the file and Medicare rules. Specifically, more than 60 hours of in-home support services is not 
covered. Based on this information, we decided that Medicare rules for coverage of additional hours of in-
home support have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
hours of in-home support.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee should be screened until 
they are 80 years old. The Plan denied your request. The Plan says the enrollee quit smoking 18 years ago in 
2004. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee is not a current smoker or former 
smoker who quit within the last 15 years. Therefore, we decided that the Plan does not have to pre-approve a 
low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on June 8, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that this exam has always been covered. The Plan 
denied your request. The Plan says this service is not a covered benefit because it was performed with a 
medical diagnosis. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers this service when it is performed as a routine exam. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you received a medical eye exam 
for a diagnosis of presence of intraocular lens, and not a routine eye exam Based on this information, we 
decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that 
the Plan does not have to pay for the eye refraction (92015) provided on June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 100 additional trips. 
 
You asked the Plan to pre-approve 100 additional trips. You say that you need transportation to get to and from 
dialysis. The Plan denied your request. The Plan says your benefit only allows for 36 trips, and you will have 
exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 36 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 100 additional trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel (87634, 87503, U0004, 
87581, 87502, 87486 and U0005) provided on October 7, 2021. 
 You asked the Plan to pay for the pathogen panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of pathogen panel testing have not been met. Specifically, the records show that a single panel was 
ordered and performed, but this service was billed by reporting individual components. Therefore, we decided 
that the Plan does not have to pay for the respiratory pathogen panel (87634, 87503, U0004, 87581, 87502, 
87486 and U0005) provided on October 7, 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 you were independent prior to your hospitalization 
and wants to return to being independent. You say you do not have support to safely discharge home and still 
requires assistance from nursing and therapy staff to get out of bed. The Plan denied your request. The Plan 
says the IRF care is not medically necessary, and your needs can be met at a lower level of care such as a 
skilled nursing facility, outpatient setting, or home health care. 
 
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 were admitted for lumbar spine surgery. Your medical problems are stable, and 
there are no complex nursing or rehabilitation needs. 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 and/or occupational therapy, there is no documented 
need for intensive rehabilitation 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service June 3, 2022. 
 You asked the Plan to pay for procedure code 76942. You say that this service was reported appropriately. The 
Plan denied your request. The Plan says payment for code 76942 is bundled into payment for code 50432. 
 
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 76942 
is a column II code to column I code 50432. 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 76942 billed for date of service June 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that admission is a medical necessity. The Plan denied 
your request. The Plan says admission was denied for skilled therapy because the enrollee has no documented 
skilled therapy needs. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is walking household distances. The enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. Our reviewer also found the enrollee does not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 a lower level of care will not be sufficient to address 
the enrollee's comorbidities and assist them in regaining their prior level of functioning. The Plan denied your 
request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower 
level of care such as a skilled nursing facility. 
 
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 enrollee was admitted for congestive heart failure. The enrollee's medical 
problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee does 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 and/or occupational 
therapy, there is no documented need for intensive rehabilitation 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 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.