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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or 
skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter 
this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan you had on February 10, 
2021. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that this was a vascular ultrasound, so 
there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment 
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 $125 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $125 copayment for the duplex scan. The duplex scan falls within the 
radiological diagnostic 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 duplex scan you had on February 10, 2021.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to waive $290 of the copayment for inpatient hospital services. We also decided 
that the Plan does not have waive the entire copayment amount for inpatient hospital services.  
 
 You asked the Plan to waive the copayment for inpatient hospital services. You say that many hospitals are still 
trying to figure out what the best course of treatment should be for each patient since there are limited studies 
on how to combat that. You also say that because of this, you feel that you should not be financially 
responsible, and you do not agree with the remaining balance of what you are expected to pay. The Plan says 
that you were charged the correct cost sharing amount. 
 
We decided that the Plan has to waive $290 of the copayment amount for inpatient hospital services.  
 
The Plan follows Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, 
accurate terms all cost-sharing information. The Plan contract says there is a $290 copayment per day for days 
1-5 for each stay inpatient hospital admission. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan must waive $290 
of the $1,740 copayment applied in this case. Specifically, the record does not show that there were two 
separate admissions to warrant an additional $290 copayment ($290 x 5 = $1,450). Therefore, we decided that 
the Plan must waive $290 of the $1,740 copayment applied for this admission.  
 
We also decided that the Plan does not have to waive the copayment for days 1 to 5 for inpatient hospital 
services. 
 
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 $1,450 
for inpatient hospital services ($290 copayment x 5 days = $1,450). Therefore, we decided that the Plan does 
not have to waive $1,450 of the copayment for inpatient hospital 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox, 200 unit injection. 
 
You asked the Plan to pre-approve Botox. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says medication that is given or supervised by a physician but is not supplied by 
the physician is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox, 200 unit injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Januvia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Januvia.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the 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: Favorable

 
We decided that the Plan has to pay for the lumbar-sacral orthosis (L0650) provided on March 5, 2021. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that this item was medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says that 2 units were billed when only 1 unit 
is allowed due to the medically unlikely edit rule. 
 
The Plan follows Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds 
the MUE value cannot be paid when the MAI value is 2. Medicare rules also say that a lumbar-sacral orthosis 
is subject to the criteria listed in the Medicare rules section.  
In this case, although the Plan has argued that the unit of service exceeds the MUE value there is no evidence 
provided that more than 1 unit of the lumbar-sacral orthosis coded as L0650 was billed. Therefore, we asked 
our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if 
the lumbar-sacral orthosis was medically necessary according to Medicare criteria. Our reviewer says that the 
requested item was medically reasonable and necessary for the enrollee's condition. Our physician reviewer 
found the enrollee is an 86-year-old man with diagnoses of low back pain, muscle spasm of back, lumbar spinal 
stenosis without neurogenic claudication, and other spondylosis, lumbar region. The enrollee was diagnosed 
with a compression fracture of T12. A back brace was ordered to allow offloading of the lumbar spine and to 
provide restriction of back motion to help with low back pain and injury. The documentation supports that the 
coverage criteria for a spinal orthosis were met 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 the lumbar-sacral orthosis have been met. Therefore, we decided that the Plan 
has to pay for the lumbar-sacral orthosis (L0650) provided on March 5, 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 laboratory services rendered on April 8, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all items and nonphysician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
We looked at the file and Medicare rules. The file shows that the services were performed while the enrollee 
was under inpatient hospital status. Payment for these services is included in payment to the hospital. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the laboratory services rendered on April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a continuous positive airway pressure (CPAP) device (E0601), 
provided on January 31, 2021, through February 27, 2021. 
 
You asked the Plan to pay for a CPAP device. You say that the item is medically necessary. The Plan denied 
your request. The Plan says that this is a duplicate. 
 
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 submit any evidence supporting that denial of payment as a 
duplicate is appropriate. Therefore, we decided that the Plan has to pay for a continuous positive airway 
pressure (CPAP) device (E0601), provided on January 31, 2021, through February 27, 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014), and the coinsurance 
for the aflibercept (J0178), provided on May 6, 2021, and May 13, 2021. 
 
You asked the Plan to waive the copayment for the eye exam, and the coinsurance for the aflibercept. You say 
that the services should be covered. The Plan denied your request. The Plan says the cost share was applied 
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 20% 
coinsurance for Medicare Part B prescription drugs and a $25 copayment for vision services in a specialist 
office.  
 
  
You have been asked to pay a 20% coinsurance for the aflibercept and a $25 copayment for the eye exam. 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 eye exam (92014), and the coinsurance for the 
aflibercept (J0178), provided on May 6, 2021, and May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 16, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on June 9, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that the member was told she could order hearing aids 
through this provider and be reimbursed. You say that the Plan should cover this. The Plan denied your request. 
The Plan says the hearing aids were purchased from an out-of-network provider. 
 
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 plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased from the Plan's hearing vendor. 
 
 
  We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of the hearing aids have not been met. Specifically, the hearing aids were not 
purchased from the Plans hearing vendor. Therefore, we decided that the Plan does not have to pay for the 
hearing aids provided on June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that this should be covered because the 
member has had multiple falls. The Plan denied your request. The Plan says that the documentation does not 
indicate that the member requires frequent and immediate need for a change in body position. 
 
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 a semi-electric hospital bed is not medically reasonable and necessary for the enrollee. The 
documentation does not clearly reveal that patient's condition has failed positioning of the bed in ways not 
feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does 
not support a need for frequent or an immediate change in body position or special attachments that cannot be 
fixed on an ordinary bed. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for a semi-electric hospital bed. 
 
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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operative vehicle. 
 
You asked the Plan to pre-approve a power operative vehicle. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested 
item. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by cane. This means that Medicare rules for coverage of a 
PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operative 
vehicle.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the clinical value and effectiveness of Keytruda for the 
enrollee's condition have not been demonstrated in the peer-reviewed literature. 
 
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 Keytruda. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 69-
year-old male who has been diagnosed with metastatic colon cancer. The enrollee has already had several prior 
lines of therapy. In this case, the requested drug is not FDA-approved for the enrollee's condition. In addition, 
the use of the requested drug is not supported by one of the major drug compendia or by clinical research that 
appears in a Medicare-approved medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you need this denture to be 
approved for coverage so you can eat. The Plan denied your request. The Plan says this service exceeds the 
maximum count allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, maxillary partial denture (D5211) is 
limited to one procedure every five plan years. The record shows that you received a maxillary partial denture 
(D5211) on April 25, 2018 and your maxillary partial denture (D5211) benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture (D5211).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for thoracoscopy, surgical, with pleurodesis (32650) provided 
October 14, 2020. 
 
You asked the Plan to pay for the surgical procedure. You say that according to your agreement, the total 
allowable indicated on the explanation of benefits is incorrect. The Plan denied your request. The Plan says the 
service is included in another service on this claim. 

 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the 
surgical procedure is a column II code to column I code 32655 (thoracoscopy, surgical, with resection-plication 
of bullae, including any pleural procedure when performed). This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for thoracoscopy, surgical, with pleurodesis (32650) 
provided October 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan tab 550mg 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 there is a lack of eligibility for coverage under Part B. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xifaxan tab 550mg for the 
enrollee.