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

 
We decided that the Plan has to pay for fundus photography with interpretation and report (92250) provided on 
January 31, 2022. 
 
You asked the Plan to pay for fundus photography. You say that this was a medically necessary service to 
document your retinal conditions and follow the progression of your ocular health which has been declining 
due to tearing and matter in your eyes. The Plan denied your request. The Plan says that this service is not 
covered by your supplemental vision 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 argued that this service is not covered by your supplemental 
(routine, non-medical) vision benefit. However, the Plan has provided no explanation as to why the fundus 
photography, which is a medical service, is not being covered under your medical benefit. Therefore, we 
decided that the Plan has to pay for fundus photography with interpretation and report (92250) provided on 
January 31, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia there is no documentation that the Keytruda at issue in this case 
meets Medicare criteria for safe and effective. The enrollee's pathology does not show a tumor mutational 
burden-high (TMB-H) [=10mutations/megabase (mut/Mb)] tumor and is not microsatellite instability (MSI)-
High. Provided records do not document a medically-accepted indication for use of Keytruda in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 the enrollee is a 48-year-old male with a medical history of obesity, chronic 
obstructive pulmonary disease, congestive heart failure and sleep apnea who was admitted to the hospital after 
repeatedly falling at home. Prior to admission to the hospital, the enrollee was noted to be able to ambulate 
household distances and require assistance with performing his activities of daily living. In this case, the 
complexity of the enrollees nursing medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees current medical 
conditions have not changed acutely and do not require physician management in an acute hospital setting. He 
does not have new neurological deficits and does not have complex medical issues, including wound care or 
bowel and bladder management. His medical and rehabilitation needs do not require the intensive 
interdisciplinary approach provided on acute inpatient rehabilitation. Therefore, the requested acute inpatient 
rehabilitation admission is not medically 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aid services (V5261, V5267, V5287) provided on 
December 18, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for hearing aid services. You say that your plan has out-of-network benefits, and you 
found a better deal with this provider. The Plan denied your request. The Plan says your routine hearing benefit 
only covers hearing aids through the Plan's specified vendor. The provider in this case is not part of the Plan's 
specified vendor network for hearing aid services. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased through the specified vendor network.  
 
 
 
 
 
 We looked at the file and the Plan's rules. The provider in this case is not part of the Plans required network. 
Based on this information, we decided that the Plan's rules for coverage of hearing aid services have not been 
met. Therefore, we decided that the Plan does not have to pay for hearing aid services (V5261, V5267, V5287) 
provided on December 18, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that this equipment is medically 
reasonable and necessary. The Plan denied your request. The Plan says this device is not medically reasonable 
and necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that the requested portable oxygen concentrator is not medically reasonable and necessary. Our 
physician reviewer found a portable oxygen concentrator (POC) is not medically necessary because coverage 
criteria are not met. This patient was recently hospitalized with hypoxic respiratory failure, possibly due to 
pneumonia. However, there is no documentation in the medical record of oxygen levels that would establish a 
need for supplemental oxygen, either at rest or with exertion. There is no documentation that the SpO2 can be 
maintained >91% with an oxygen conserving device and flow rate of 1 to 4 L/min. The information indicates 
the patient wants to use only the POC, but Medicare will not cover a POC for use as a stationary concentrator 
for oxygen during sleep. The criteria for coverage have not been met. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says a Medicare Advantage Plan can require a trial of a preferred drug to treat a medical 
condition before covering another non-preferred drug. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the Plan requires a 
trial of Bevacizumab/Avastin before they will approve the requested drug. In this case, the patient has not tried 
and failed the required drug. There is no documentation provided indicating that the plans required drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 Eylea for the enrollee.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the deductible for ultrasound on December 22, 2021. 
 
You asked the Plan to waive the deductible for ultrasound. You say that this was paid last year and there is a 
CT law so it must be paid. The Plan denied your request. The Plan says that the cost-sharing you are being 
charged is correct. 
 
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 did not submit the correct Evidence of Coverage. This means that we 
cannot determine the cost you are being asked to pay is correct or justified by the contract. It is the burden of 
the Health Plan to substantiate their decision with evidence. In this case, the decision has not been substantiated 
so we must find in your favor. Therefore, we decided that the Plan has to waive the deductible for ultrasound 
on December 22, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 3, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses provided on February 27, 2022. 
 You asked the Plan to pay for eyeglasses. You say that your benefit covers up to $150 for eyeglasses, and you 
would like reimbursement for this claim. The Plan denied your request. The Plan says you previously used your 
routine eyewear benefit in August of 2020, which is less than 24 months before the date in question. This 
means that your eyewear benefit was still exhausted when these eyeglasses were purchased. 
 
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 these services up to $150 once every 24 months. 
 
We looked at the file and the Plan's rules. The record shows that you exhausted your routine eyewear benefit 
less than 24 months before the date in question. Based on this information, we decided that the Plan's rules for 
coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyeglasses provided on February 27, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for prolonged evaluation and management services (procedure code 
99358) provided to the enrollee on January 18, 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 that a corrected claim should be filed. 
 
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 99358 is "Prolonged evaluation and management service before and/or after direct patient care; first 
hour." 
 
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 supported by the medical records. Our reviewer found that coding with CPT 99358 is accurate, 
according to the medical documentation. The document by the provider stated that additional indirect care as 
well as additional direct care was rendered. This coding is correct. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
prolonged evaluation and management services (procedure code 99358) provided to the enrollee on January 18, 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on December 21, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service.  
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC genetic testing is not a 
covered benefit. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the FANCC genetic testing provided on 
December 21, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for an office consultation. We decided that the Plan does not have to waive 
the copayment for a diagnostic ophthalmic ultrasound.  
 You asked the Plan to pay for and waive the copayment for an office consultation and a diagnostic ophthalmic 
ultrasound. You say that the Plan should have paid the billed amount since there was an authorization on file. 
The Plan denied your request. The Plan says that you were charged the correct cost sharing amount. 
 
We decided that the Plan has to pay for an office consultation.  
 
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 failed to provide any reason or evidence for denying the office 
consultation (99245). Therefore, we decided that the Plan has to pay for an office consultation provided on 
March 14, 2022.  
 
We also decided that the Plan does not have to waive the copayment for a diagnostic ophthalmic 
ultrasound. 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each Medicare-covered standard x-ray and ultrasound. Medicare rules say that when services or 
supplies are rendered by a non-contracting, original Medicare, participating provider, there is no balance billing 
paid by either the plan or the enrollee. 
 
You have been asked to pay $45.43, which is less than the $50 copayment for a diagnostic ophthalmic 
ultrasound. A diagnostic ophthalmic ultrasound falls within the outpatient diagnostic tests and therapeutic 
services and supplies. 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. 
The Plan has reimbursed you for these services, minus your applicable cost-sharing; therefore, the Plan is not 
responsible for paying the balance that remains beyond the Medicare allowable amount. Therefore, we decided 
that the Plan does not have to waive the copayment for a diagnostic ophthalmic ultrasound provided on March 
14, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for intravitreal injection of a pharmacologic 
agent, separate procedure (67028) injection, bevacizumab, 10 mg (J9035) comprehensive eye exam (92014) 
Fluorescein angiography (includes multi-frame imaging) with interpretation and report (92235) Scanning 
computerized ophthalmic diagnostic imaging (92134) provided March 2, 2022 to March 7, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic eye exam and injection services. You say that 
you are appealing for the Plan to approve payment of this claim. The Plan denied your request. The Plan says 
the claims were processed with the correct cost shares per the Evidence of Coverage 
 
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 Part B drugs, including chemotherapy drugs and $40 copayment for each Medicare covered eye exam.  
 
You have been asked to pay $54.08 ($14.08 coinsurance + $40 copayment) for the diagnostic eye exam and 
injection services. The diagnostic eye exam and injection services falls within the Medicare Part B prescription 
drugs and Vision care 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 intravitreal 
injection of a pharmacologic agent, separate procedure (67028) injection, bevacizumab, 10 mg (J9035) 
comprehensive eye exam (92014) Fluorescein angiography (includes multi-frame imaging) with interpretation 
and report (92235) Scanning computerized ophthalmic diagnostic imaging (92134) provided March 2, 2022 to 
March 7, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services you received on January 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were 
billed with a non-covered diagnosis code. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the services by a contract provider. The file does not show that the Plan provided notice 
that the services would not be covered. Under Medicare rules, this means the services is considered approved 
by the Plan. Therefore, we decided that the Plan has to pay for the services you received on January 18, 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.