Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug 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 Tecentriq. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of Stage IIB Non Small Cell Lung Cancer that is PDL-1 positive 
and negative for mutations. The documentation indicates that the enrollee has undergone resection but has not 
received adjuvant chemotherapy. The Food and Drug Administration (FDA) has not stated that the requested 
drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the enrollee 
does not meet criteria for the requested drug.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel testing provided on July 11, 2022. 
 
You asked the Plan to pay for the panel testing. The Plan denied your request. The Plan says a panel test must 
not be unbundled and billed as individual components. 
 
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 find that the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the respiratory panel testing provided on July 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a toric lens. 
 
You asked the Plan to pre-approve a toric lens. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve a toric lens.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210) provided on October 11, 2022. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images (D0210). You say that you 
were not aware that this type of x-ray was not covered. The Plan denied your request. The Plan says this 
service is not covered under the benefit package. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
intraoral - complete series of radiographic images (D0210) provided on October 11, 2022.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 respiratory failure and COVID 19 infection. Medical 
problems are stable. 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. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that you 
believe that the receiver and sensor should be covered. The Plan denied your request. The Plan says the 
enrollee does not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home modification (S5165). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the enrollee was misinformed that this 
would be covered. The ramp will not be attached to the home. You also say that a metal one would go to the 
side of the house without an attachment. The Plan denied your request. The Plan says Medicare does not cover 
these items as they do not fit the definition of durable medical equipment to both serve a medical purpose and 
for use in the enrollees home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a home modification (S5165).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan of extremity veins (93970) provided on 
November 15, 2021. 
 
You asked the Plan to pay for a duplex scan of extremity veins. You say that you want the Plan to pay for the 
service. The Plan denied your request. The Plan says the provider has not submitted any clinical records to 
support the medical necessity of the service. As such, the service remains denied based upon Medicare 
guidelines. 
 
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 a duplex scan of extremity veins have 
been met. There are no medical records within the casefile. Without the requested clinical information, we are 
unable to determine if the service was medically necessary. Therefore, we decided that the Plan does not have 
to pay for a duplex scan of extremity veins (93970) provided on November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitoring (CGM) 
device. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM will prevent hypoglycemia allowing the 
enrollee to improve their diabetes control. The Plan denied your request. The Plan says the enrollee's treatment 
regimen is not being frequently adjusted by the enrollee; therefore, the CGM is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
therapeutic CGM device is not medically necessary. Our physician reviewer found that the Plan requires that 
the enrollee be on minimal infecting dose and that insulin doses are adjusted during the day acc to bg level to 
cover the CGM device. This enrollee is not using a ss and is only on 1 shot of insulin dose. So, although the 
CGM might indeed help them to avoid low and/or high bgs, the enrollee does not meet the criteria for the CGM 
at this time. 
 
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 CGM have been met. Therefore, we decided that the Plan does not have to 
pre-approve a therapeutic continuous glucose monitoring (CGM) device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 
You asked the Plan to pre-approve Lucentis. You say that the enrollee has received Eylea samples, and the 
physician wants to treat them with Lucentis. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested 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 Lucentis. Our reviewer says that the 
enrollee does not meet the coverage criteria for Lucentis. Our physician reviewer found there is no indication 
that the enrollee has tried and failed the required drug. Our reviewer also found that there is no indication that 
the plan's required drug 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 Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
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 February 22, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
you disagree with the overpayment because the enrollee is not confine or inpatient. The Plan denied your 
request. The Plan says there are no authorizations on file for Ambulance Service, which makes the 
overpayment valid. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that ambulance transports to or from a diagnostic or 
therapeutic site other than a hospital or renal dialysis facility is included in SNF CB and may not be billed as 
Part B services to the A/B MAC (A), (B), or (HHH) when the beneficiary is in a Part A stay. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the non-emergency ambulance transportation and ground mileage have not been met. Therefore, 
we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on February 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission is medically 
necessary. The Plan denied your request. The Plan says an inpatient admission is not medically necessary. 
 
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 should present for, undergo, and be monitored following the procedure 
as an outpatient.  
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 acute inpatient hospital care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services (G0156). 
 
You asked the Plan to pre-approve HHA services. The Plan denied your request. The Plan says the enrollee 
does not meet the level of care requirements for HHA services because they are only dependent on 
supervision/limited assistance for some activities of daily living. The Plan also says the enrollee does not have 
wounds, catheter, colostomy, etc. that would require the assistance of an HHA. 
 
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 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 HHA services. Our reviewer says that 
the HHA services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not show clinical reasoning for HHA service, or any care plan that would require HHA 
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 HHA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health aide (HHA) services (G0156).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy. 
 
You asked the Plan to pre-approve the therapy services. You say that additional physical therapy sessions are 
medically necessary. The Plan denied your request. The Plan says additional physical therapy is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found documentation does not support the need for additional physical 
therapy visits which are not medically necessary for coverage. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and supplies. You say that the requested CGM and 
supplies are medically necessary due to type 2 diabetes mellitus without complications. The Plan denied your 
request. The Plan says you do not meet criteria for approval of the requested CGM and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14-day 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14-day continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on 
August 30, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 
copayment for outpatient diagnostic tests/Medicare-covered standard x-ray and ultrasound.  
 
You have been asked to pay a $55 copayment for outpatient diagnostic tests. However, you are only being 
asked to payThis item/service falls within the outpatient diagnostic tests/Medicare-covered standard x-ray and 
ultrasound 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 outpatient diagnostic tests 
provided on August 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve esophagogastric fundoplasty surgical laparoscopy. 
 
You asked the Plan to pre-approve esophagogastric fundoplasty surgical laparoscopy. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are 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 pre-approve esophagogastric fundoplasty surgical 
laparoscopy. 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 moderate sized hiatal hernia without 
reflux. The enrollee is not receiving proton pump inhibitor therapy. The record provided is insufficient to 
establish the medical necessity of the requested procedure at this time. Therefore, the enrollee does not meet 
criteria for the requested 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 esophagogastric fundoplasty surgical laparoscopy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve esophagogastric fundoplasty surgical laparoscopy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests and an outpatient 
surgery provided on July 14, 2022, to August 30, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests and an outpatient surgery. You say 
that you disagree with the copayment. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient diagnostic tests/Medicare-covered service and a $390 copayment for outpatient 
surgery.  
 
You have been asked to pay a $275 copayment for outpatient diagnostic tests and a $390 copayment for an 
outpatient surgery. The total allowed amount is $665 ($275 + $390 = $655). However, you are only being asked to pay $622.45 which is less than the required amount. 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 outpatient diagnostic tests and an outpatient surgery provided on July 14, 2022, to August 30, 2022.