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

 
We decided that the Plan has to provide reimbursement for the 2022 annual golf club membership purchased 
on October 5, 2021. 
 
You asked the Plan to provide reimbursement for the membership. You say that your country club said if you 
wanted to renew your annual membership for 2022, that you had to do so by October 2021. The Plan denied 
your request. The Plan says that you have exhausted your Wellness Wallet benefit limit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
up to $400 each year for fitness memberships. 
 
The documentation clearly shows the payment is for a membership benefit in which the dates of service will 
exclusively be in 2022. It is not an extension of services that begin in 2021 and extend into the following year. 
Therefore, the membership is reimbursable under the 2022 wellness benefits. We decided that the Plan has to 
provide reimbursement for the 2022 annual golf club membership purchased on October 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage rules have not been met. 
 
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 Opdivo. Our reviewer says that Opdivo 
is not medically necessary. Our physician reviewer found Opdivo is not FDA-approved for the enrollee's 
diagnosis of metastatic esophageal adenocarcinoma that has progressed on chemotherapy. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies 
provided on December 27, 2021. 
 
You asked the Plan to pay for the CGM and supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says there is insufficient information submitted. 
 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 and 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 the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor (CGM) and supplies provided on December 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lonsurf for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered 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 Lonsurf for the enrollee.  
 
Benefits for this drug 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve root canal-Teeth 22 and 24 and crown-Teeth 22, 24 and 
26. 
 
You asked the Plan to pre-approve root canal-Teeth 22 and 24 and crown-Teeth 22, 24 and 26. You say that 
you are in delicate health and need these services. The Plan denied your request. The Plan says your benefit has 
been exhausted for the 2022 year. 
 
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.  Supplemental dental benefits 
coverage allows crown(s) one procedure code per calendar year and root canals one procedure code per 
calendar year. 
 
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. You previously received a covered root canal on June 21, 2022, and a 
covered crown on June 21, 2022. Therefore, these benefits were exhausted for the calendar year 2022. 
Therefore, we decided that the Plan does not have to pre-approve root canal-Teeth 22 and 24 and crown-Teeth 
22, 24 and 26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state received on January 17, 
2022. 
 
You asked the Plan to pay for the determination of refractive state. You say that you disagree with the plan's 
denial. The Plan denied your request. The Plan says the services received are not a covered benefit without a 
vision exam.  
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 they are included within a vision exam. 
 
We looked at the file and the Plan's rules. Review of the file does not support that a vision exam was provided 
on the same date of service as the refraction. Based on this information, we decided that the Plan's rules for 
coverage of the determination of refractive state have not been met. Therefore, we decided that the Plan does 
not have to pay for the determination of refractive state received on January 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient hospital 
care is medically necessary. The Plan denied your request. The Plan says the requested inpatient hospital care 
does not meet criteria. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient hospital care are not met in this 
case. Our physician reviewer found the documentation indicates that the enrollee is undergoing a planned left 
shoulder arthroplasty. She is medically stable and has been provided medical clearance to undergo this elective 
procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. 
The procedure is currently approved as an ambulatory procedure. There is no documentation provided to 
support the expectation the enrollee will require a greater than 2 midnight stay. The review has determined that 
the record does not show that at the time of inpatient admission the admitting physician reasonably expected 
that the enrollee's necessary hospital care (including earlier ED and/or observation 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 been met. Therefore, we decided that the Plan 
does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitoring (CGM) system. 
 
You asked the Plan to pre-approve a CGM system. 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. 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 a 
CGM system have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitoring (CGM) system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99211) provided on January 19, 2022 to 
January 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the out-of-network services were not pre-authorized. There were 
network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for 
these services. Therefore, we decided that the Plan does not have to pay for physician services (99211) 
provided on January 19, 2022 to January 28, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sarclisa. 
 
You asked the Plan to pre-approve Sarclisa. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Sarclisa. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found use is not supported by major drug 
compendia and is not supported by phase III clinical trials. The use is the ongoing subject of phase II trials. The 
service is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Sarclisa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Sarclisa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection services. 
 
You asked the Plan to pre-approve epidural steroid injection services. You say that the enrollee has radicular 
pain and has pain that is debilitation. You say that the office notes provided support the need for the requested 
injection services. The Plan denied your request. The Plan says the requested services are not reasonable and 
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 epidural steroid injection services. Our 
reviewer says that epidural steroid injection services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the radicular pattern described is consistent with either a L2-L3 lesion 
or from facet dysfunction.  In either event, doing an L5 transforminal injection is not indicated as it will not 
effectively address the lesion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural steroid injection services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve epidural steroid injection services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic eye exam (99204), provided 
on February 23, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic eye exam. You say that the service 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 $30 
copay for vision care.  
 
You have been asked to pay a $30 copay for the diagnostic eye exam. This service falls within the vision care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic eye exam (99204), 
provided on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a respiratory viral panel provided to the enrollee on February 
1, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered 
 
The Plan must follow Medicare rules. Medicare rules say that multiplex polymerase chain reaction (PCR) 
respiratory viral panels of 6 or more pathogens are non-covered.  
 
This level of testing is not covered by Medicare currently. 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 a respiratory viral panel provided to the enrollee on February 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services (99223) provided July 11, 2021. 
 
You asked the Plan to pay for the inpatient services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the allowed amount. 
 The Plan must follow 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.  
 
In this case, the MUE for CPT code 99223 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient 
services (99223) provided July 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 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 the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have documented skilled nursing or skilled therapy needs. The enrollee is functioning at a level 
commiserate with her weight-bearing restriction. The enrollees care needs, as a practical matter, can be 
provided at a lower level of care. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the computed tomographic (CT) angiography (70496) provided on 
January 29, 2022. 
 
You asked the Plan to pay for the CT angiography. You say that the enrollee had multiple claims on this date of 
service. The Plan denied your request. The Plan says that this is a duplicate claim that has already been 
considered for payment. 
 
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 file does not support that this services has been paid previously. 
Therefore, we decided that the Plan has to pay for the computed tomographic (CT) angiography (70496) 
provided on January 29, 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: Favorable

 
We decided that the Plan has to pre-approve Mvasi. 
 
You asked the Plan to pre-approve Mvasi. You say that the records provided support the need for the requested 
drug. The Plan denied your request. The Plan says that the requested drug does not meet medical necessity 
guidelines. 
 
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 Mvasi. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the requested use of Mvasi is FDA approved 
for use extrapolated from vulvar cancer. The documentation supports that the requested drug is safe and 
effective and otherwise reasonable and necessary 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 Mvasi have been met. Therefore, we decided that the Plan has to pre-approve 
Mvasi.  
 
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 Opzelura cream. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered 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 Opzelura cream.  
 
Benefits for this drug 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve corneal pachymetry (76514) provided on July 16, 2021. 
 
You asked the Plan to pre-approve corneal pachymetry. You say that corneal pachymetry is medically 
necessary. The Plan denied your request. The Plan says corneal pachymetry is experimental. 
 
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 corneal pachymetry. Our reviewer says 
that corneal pachymetry is not considered medically reasonable and necessary. Our physician reviewer found 
that the clinical documentation does not support that corneal pachymetry, which maps corneal thickness, is 
medically reasonable and necessary for the enrollee 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 corneal pachymetry have not been met. Therefore, we decided that the Plan 
does not have to pre-approve corneal pachymetry (76514) provided on July 16, 2021.