Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy. 
 
You asked the Plan to pre-approve radiation therapy. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that proton beam therapy will be considered medically 
reasonable and necessary for certain circumstances. 
 
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 radiation therapy. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found since the case file does not 
adequately document need, using quantifiable dosimetric measures, showing an intensity-modulated radiation 
therapy (IMRT) or conventional 3D conformal plan that would be unacceptable, the LCD criteria are not 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 radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiation therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), power seat elevation 
(E2300), expandable controller (E2377), and harness (E2313). 
 
You asked the Plan to pre-approve an electronic connection, power seat elevation, expandable controller, and 
harness. 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 follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
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 an electronic connection, power seat 
elevation, expandable controller, and harness. Our reviewer says that the services are not medically necessary. 
Our physician reviewer found you do not require a power seat elevation or stand accessory as these do not 
serve a medical need. You have sufficient strength in your upper extremity to use standard switches for power 
drive and use a standard joystick. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, power seat elevation, expandable controller, and 
harness have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), power seat elevation (E2300), expandable controller (E2377), and harness (E2313).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 
 
You asked the Plan to pre-approve Rituxan. 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. 
 
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 Rituxan. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Plan requires a trial of drug Ruxience 
and Truxima before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drugs. The plans required drugs 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 Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for decortication, pulmonary (separate procedure); total 
(procedure code 32220) provided to the enrollee on March 23, 2021. 
 
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 there is a more appropriate CPT code (32652) is supported for the thoracoscopic total pulmonary 
decortication performed thoracoscopically. 
 
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 32220 is "Decortication, pulmonary (separate procedure); 
total." 
 
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 operative report describes a 
VATS decortication.  In this case, there is a more appropriate code to report for Thoracoscopy (Video-Assisted 
thoracic surgery (VATS). Therefore, this procedure code cannot be verified.  
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 decortication, pulmonary (separate procedure); total (procedure code 32220) provided to the 
enrollee on March 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric services provided on March 15, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for psychiatric services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee must receive care from a network provider. 
 
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 psychiatric services provided on March 15, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on August 1, 2022. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says eye refractions 
are only covered by your Plan if performed by a participating vision provider and performed as a routine 
screening. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the 
Plan does not have to pay for an eye refraction provided on August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a remote pacemaker evaluation provided on 
June 17, 2022. 
 
You asked the Plan to waive the copayment for a remote pacemaker evaluation. You say that you never went to 
the provider's office on that date and the provider has never performed this test in his office. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for each diagnostic procedure and test.  
 
 
 
 
 
 
 You have been asked to pay $22.59 for the remote pacemaker evaluation, which is less than the standard $30 
copayment. This item/service falls within the diagnostic procedure and test 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 a remote pacemaker evaluation provided on June 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025) and progressive lenses (V2781) 
provided on May 26, 2022.  
You asked the Plan to pay for deluxe frames (V2025) and progressive lenses (V2781). You say that the Plan 
told you to go to this provider. The Plan denied your request. The Plan says the member chose to take a 
promotional discount rather than use the insurance. 
 
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 when the glasses that are purchased are not on sale, combined with 
any other store discounts, coupons, or promotional codes. 
 
We looked at the file and the Plan's rules. The Plan rules say that the $150 only applies to these services when 
the glasses that are purchased are not on sale, combined with any other store discounts, coupons, or 
promotional codes. The record shows that the glasses were purchased with a discount. Please note that although 
these items are not covered with this benefit, the Plan has made a partial reimbursement. Based on this 
information, we decided that the Plan's rules for coverage of deluxe frames (V2025) and progressive lenses 
(V2781) have not been met. Therefore, we decided that the Plan does not have to pay for deluxe frames 
(V2025) and progressive lenses (V2781) provided on May 26, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for DecisionDx-Melanoma testing (81529) provided on May 18, 2022. 
 
You asked the Plan to pay for DecisionDx-Melanoma testing. You say that this test was medically necessary 
and should be paid. The Plan denied your request. The Plan says that this test was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for DecisionDx-Melanoma testing. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee met all of the criteria for coverage of this test, and this test meets the 
criteria for coverage as part of the technical assessment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-Melanoma testing have been met. Therefore, we decided that the 
Plan has to pay for DecisionDx-Melanoma testing (81529) provided on May 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
October 17, 2021, to October 25, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this was 
medically necessary. The Plan denied your request. The Plan says the DRG was adjusted.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code N17.0. 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 pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the review has determined that the records did not support the use of N17.0 (acute kidney 
failure) as a valid diagnosis for this stay.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from October 17, 2021, to October 25, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan (rituximab) injections. 
 
You asked the Plan to pre-approve the Rituxan treatments. You say that this drug should be approved. The Plan 
denied your request. The Plan says there is no reason that the preferred drug cannot be used. 
 
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 Rituxan treatments. Our reviewer 
says that the requested drug is not shown to be reasonable and necessary based on step therapy guidelines. Our 
physician reviewer found the Plan requires a trial of Ruxience and Truxima (rituximab biosimilars) before they 
will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). 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 Rituxan treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Rituxan (rituximab) injections.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cuvitru. 
 
You asked the Plan to pre-approve Cuvitru. You say that Cuvitru is indicated for the treatment of Common 
Variable Immunodeficiency. You say that subcutaneous form of immunoglobulin is safer and a more 
appropriate option over the intravenous form. The Plan denied your request. The Plan says the enrollee must 
have tried or cannot use Xembify. 
  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 Cuvitru. Our reviewer says that the 
enrollee has tried and failed the required drug. Our physician reviewer found that there is no indication that the 
Plan's required drug would likely be less effective or 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 Cuvitru have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Cuvitru.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses provided on July 12, 2022. 
 
You asked the Plan to pay for progressive lenses. You say that without progressive lenses you will need three 
pairs of glasses. The Plan denied your request. The Plan says progressive lenses are an upgrade and are not 
covered. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 We looked at the file and the Plan's rules. The file shows that the Plans vision benefit says that additional 
upgrades, extra charges and/or any customizations are not covered, e.g. tintings, coatings and/or special lens 
materials. Therefore, we decided that the Plan does not have to pay for progressive lenses provided on 
July 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 
23, 2021, through November 24, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was 
appropriate in this case. The Plan denied your request. The Plan says there was no need for over two midnights 
of hospital care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was seen in the hospital on November 23, 2021, due to left flank pain 
and blood in the urine. The record indicated that he was found to have a 0.4 cm stone at in the ureter on 
imaging with no left hydronephrosis. He was monitored overnight with improvement in creatinine. He was 
discharged home the next morning. The review has determined that the record showed that at the time of 
inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from November 23, 2021, through 
November 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from March 8, 2022, 
to March 12, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are a widow, 89 years 
old, and have a limited income. You are asking that this charge be considered for payment. 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 for each Medicare-
covered hospital stay you must pay a $310 copayment per day for days 1 to 6; $0 copayment per day for days 7 
to 90.  
 
 
 
 You have been asked to pay $1,240 for inpatient hospital care ($310/day x 4 days = $1,240). This item/service 
falls within the inpatient hospital 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 
inpatient hospital care from March 8, 2022, to March 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-Melanoma testing (81529) provided on June 27, 
2022. 
 
You asked the Plan to pay for DecisionDx-Melanoma testing. You say that this test was medically necessary 
and should be paid. The Plan denied your request. The Plan says this test was not medically necessary. 
 
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 pay for DecisionDx-Melanoma testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee does not meet the criteria outlined in the Local Coverage 
Determination 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 DecisionDx-Melanoma testing have not been met. Therefore, we decided that 
the Plan does not have to pay for DecisionDx-Melanoma testing (81529) provided on June 27, 2022.