Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the drug injection provided on December 6, 2022. 
We also decided that the Plan does not have to waive the copayment for the nuclear medicine heart study 
provided on December 6, 2022.  
 You asked the Plan to waive the cost share for the nuclear heart study and drug injection. You say that you did 
not expect this high of a copayment and would not have gotten the services if you had known. The Plan says 
that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the drug injection provided on December 6, 
2022.  
 
You have been asked to pay 20% coinsurance for the drug injection. According to Medicare, the injection 
(J2785) that assessed a cost share amount is considered a packaged code and is not separately payable. This 
code is also excluded from the physicians free schedule. Therefore, we decided that the Plan has to waive the 
coinsurance for the drug injection.  
 
We also decided that the Plan does not have to waive the copayment for the nuclear heart study provided 
on December 6, 2022. 
 
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 $275 
copayment for in-network diagnostic radiology services, including nuclear medicine tests.  
 
You have been asked to pay a $275 copayment for the nuclear medicine heart study. This item/service falls 
within the outpatient diagnostic tests and therapeutic services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the nuclear medicine heart study provided on December 6, 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 use of Keytruda, Atropine Sulfate, Leucovorin Calcium, 
Dexamethasone Sodium Phosphate, Fluorouracil, Irinotecan, and Oxaliplatin. 
 
You asked the Plan to pre-approve drug combination. You say that you are appealing with supporting records. 
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 drug combination. Our reviewer says 
that the enrollee does not meet criteria for this drug combination. Our physician reviewer found this 
combination is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. This combination 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 drug combination have not been met. Therefore, we decided that the Plan does 
not have to pre-approve use of Keytruda, Atropine Sulfate, Leucovorin Calcium, Dexamethasone Sodium 
Phosphate, Fluorouracil, Irinotecan, and Oxaliplatin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
 
 
 
 You asked the Plan to pre-approve a semi-electric hospital bed. You say that you are currently using a blow-up 
mattress and when you wake up, you feel dizziness and temporarily forget that you need assistance to get out of 
the bed and fall. The bed is soaked in urine, and you were told that you would get a hospital bed within 30 
days. The Plan denied your request. The Plan says no documentation found that you have conditions that 
require frequent change of position, elevation of head of the bed for more than 30 degrees due to congestive 
heart failure, chronic pulmonary disease, problems with aspiration or traction equipment which can only be 
attached to a hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you have prostatic 
hypertrophy and was recently hospitalized with recurrent urinary retention. A catheter was placed. Per NCD 
280.7, you do not have a condition requiring positioning not possible with a regular bed or a need for frequent 
and prompt position changes. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781) and an addition to lower limb 
prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968). 
 
You asked the Plan to pre-approve prosthetics. You say that the prosthetics are medically necessary. The Plan 
denied your request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a high above knee amputation. She is currently non ambulatory. The vacuum 
pump system has not been shown to reliably improve function. There is no evidence the enrollee will be a K3 
ambulator and need an advanced ankle system. Per L33787 and A52496. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition to lower limb prosthesis, vacuum pump, residual limb volume management 
and moisture evacuation system (L5781) and an addition to lower limb prosthesis, multiaxial ankle with swing 
phase active dorsiflexion feature (L5968).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary for the enrollee. 
The Plan denied your request. The Plan says that the Medicare criteria was not met. 
 
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. Specifically, the Plan did not collect medical records from their participating 
provider who ordered the requested CGM. Participating providers are considered agents of the Plan. Without 
this necessary documentation we are unable to make a determination as to whether the enrollee has met the 
criteria for coverage of a CGM. Prior authorizations are not an acceptable substitution for medical records. 
Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor (CGM).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on March 30, 2022. 
 
You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 imaging services provided have been 
met. The provider has not provided medical records to support the services as billed. Therefore, we decided 
that the Plan does not have to pay for imaging services provided on March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood bank services provided on December 11, 2022. 
 You asked the Plan to pay for blood bank services. You say that the enrollee was not enrolled in hospice at the 
time of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 9, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for blood bank services 
provided on December 11, 2022.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pay 50% of the allowed amount for the canalith repositioning procedures 
(95992). 
 
You asked the Plan to pay 50% of the allowed amount for the canalith repositioning procedures (95992) 
provided from February 23, 2022, to June 3, 2022. You say that you need to be reimbursed the allowed amount 
by the Plan. The Plan says that the cost share was charged correctly. 
 
We decided that the Plan has to pay 50% of the allowed amount for the canalith repositioning 
procedures (95992).  
 
The Plan follows Medicare rules. Medicare rules say that coinsurance is a fixed percentage of the total amount 
paid for a health care service that can be charged to an enrollee on a per-service basis. Procedure code 95992 is 
considered a therapy service when performed and billed by a physical therapist. This service was performed by 
an out-of-network therapist which would apply 50% coinsurance. The case file shows that the Plan charged you 
100% of the allowed amount for this service. Therefore, we decided that the Plan has to pay 50% of the 
allowed amount for the canalith repositioning procedures (95992).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath / shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you would like reconsideration because the 
requested shower chair is medically necessary. The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath / shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment and abutment supported 
porcelain (D6058, D6057). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted with the Plans prior authorization. 
Therefore, we decided that the Plan does not have to pre-approve an additional custom fabricated abutment and 
abutment supported porcelain (D6058, D6057).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the lumbar-sacral orthosis provided on 
October 12, 2022. 
 
You asked the Plan to waive the coinsurance for the lumbar-sacral orthosis. You say that you were told the 
orthotic would be covered. 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 in-network prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for the lumbar-sacral orthosis. This item/service falls within the 
in-network prosthetic devices and related 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. The total you owe is $170.51 ($852.56 allowed amount x 20% = 
$170.51). Therefore, we decided that the Plan does not have to waive the coinsurance for the lumbar-sacral 
orthosis provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99220 on March 26, 2022.. We decided that the Plan does not have to 
pay for the rest of services.  
 
You asked the Plan to pay for observation care (procedure codes 99217, 99220, 99226) rendered from March 
26, 2022, to March 28, 2022. You say that this should be paid for. The Plan says that the records do not support 
the services billed.  
We decided that the Plan has to pay for 99220 on March 26, 2022.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
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 for CPT 99220 on March 26, 2022. Our reviewer says 
that this code is appropriate, as the medical decision making was of high complexity, and the time requirements 
were 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 the services have been met. Therefore, we decided that the Plan has to pay for 
99220 on March 26, 2022..  
 
We also decided that the Plan does not have to pay for the rest of services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 for the rest of the services. Our reviewer says that the 
medical records are only for March 26, 2022. There are no records for the rest of the dates of service and the 
rest of the services. The documentation must indicate the correct date of service. 
 
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 rest of services have not been met. Therefore, we decided that the Plan does 
not have to pay for the rest of services. 
 
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: Testing
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the drug injections provided on November 14, 2022. 
We also decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided 
on November 14, 2022.  
 
You asked the Plan to waive the cost share for the diagnostic colonoscopy and drug injections. You say that 
you thought this was a screening colonoscopy and would have no cost share amount. The Plan says that this 
cost sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the drug injections.  
 
You have been asked to pay 20% coinsurance for each drug injection. According to Medicare, the injections 
(J7120, J3010, J2250) that assessed cost share amounts are considered packaged codes and are not separately 
payable. These codes are also excluded from the physicians free schedule. Therefore, we decided that the Plan 
has to waive the coinsurance for the drug injections provided on November 14, 2022. 
 
We also decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy. 
 
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 $290 
copayment for in-network outpatient surgery.  
 
The records show you had polyps removed during the colonoscopy. You have been asked to pay a $290 
copayment for the diagnostic colonoscopy. This item/service falls 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 cost share for the diagnostic colonoscopy provided on 
November 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LDCT scan for lung cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that enrollee started smoking in their 
twenties and smoked 1 pack a day. The Plan denied your request. The Plan says the enrollee must be between 
50 and 77 years of age. 
 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 does not fall within the age range. 
Therefore, we decided that the Plan does not have to pre-approve a LDCT scan for lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve native coronary artery catheterization with left heart 
catheterization. 
 
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 echo was essentially normal with mild impaired relaxation. 
 
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 for performance of cardiac catheterization. A 
radionuclide stress test was performed in 2/2023 and was normal. The medical records provided do not support 
the rationale for this invasive imaging study. Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be considered medically appropriate and 
necessary in this patient's 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 native coronary artery catheterization with left heart catheterization.