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

 
We decided that the Plan does not have to pre-approve Opdivo and Ipilimumab. 
 
You asked the Plan to pre-approve Opdivo and Ipilimumab. 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 Opdivo and Ipilimumab. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the Food and Drug 
Administration 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. No literature from Medicare approved cancer journals were submitted for review. 
The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 and Ipilimumab have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Opdivo and Ipilimumab.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right lower extremity revascularization for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered not medically necessary for claudication due to isolated infrapopliteal 
artery disease. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that NCD 20.7 does not provide coverage for percutaneous transluminal angioplasty of the anterior and 
posterior tibial arteries. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve right lower extremity revascularization for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (99328), debridement of nails 
(11721), and removal of nail bed (11750) provided on February 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services, debridement, and removal. The Plan denied your 
request. The Plan says the services were provided out-of-network and were not approved in advance. 
 
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 the home health services (99328), debridement of 
nails (11721), and removal of nail bed (11750) provided on February 5, 2022, by an out-of-network (OON) 
provider.
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 the 
services are not medically necessary. Our physician reviewer found the beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81295, 81298, 81317, 81162, 
and 81309 provided on February 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 CPT codes 81295, 81298, 81317, 81162, and 81309 are not supported in the medical record. 
Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes 
will be considered part of the same panel. A panel constitutes a single procedural service, so one code should 
be billed for the panel. Review of the file does not support that only one code was billed for the panel provided.  
 Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81295, 
81298, 81317, 81162, and 81309 provided on February 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation therapy provided on February 14, 2022, to February 
17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for radiation therapy. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial is based on no prior authorization on file and no medical 
necessity for services had been determined prior to claims submission. 
 
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 radiation therapy provided on February 14, 2022, 
to February 17, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81201, 81317, 81404, 81406, 
81403, 81432, 81408, 81407, 81298, 81295, 81479, and 81405 provided on October 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 CPT codes 81201, 81317, 81404, 81406, 81403, 81432, 81408, 81407, 81298, 81295, 81479, and 
81405 are not supported in the medical record. Specifically, when a laboratory assays two or more genes in an 
enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a 
single procedural service, so one code must be submitted for the panel. Review of the file does not support that 
only one code was submitted for the panel provided. 
 
In this case, we have confirmed that code 81298 is a column II code to column I code 81432 with a modifier 
indicator of 0. The column II code is therefore not payable. We have also confirmed that code 81295 is a 
column II code to column I code 81432 with a modifier indicator of 0. The column II code is therefore not 
payable. 
 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81201, 
81317, 81404, 81406, 81403, 81432, 81408, 81407, 81298, 81295, 81479, and 81405 provided on October 7, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 vaccine services provided from March 31, 
2022, through April 30, 2022. 
 
You asked the Plan to pay for the COVID-19 vaccine services. You say that you would like this claim 
reprocessed and approved for payment for medical necessity. The Plan denied your request. The Plan says 
payment is not made through the enrollee's Medicare Advantage plan for these services. 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that pursuant to CMS guidance Medicare payment for 
COVID vaccinations administered during calendar years 2020 and 2021 to MA beneficiaries will be made 
through the Medicare Fee for Service program. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 vaccine services have not been met. Therefore, we decided that the Plan does not 
have to pay for the COVID-19 vaccine services provided from March 31, 2022, through April 30, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
February 2, 2021. 
 
You asked the Plan to pay for an emergency department visit. You say that the claim was submitted within the 
timely filing limits. The Plan denied your request. The Plan says Medicare denies a claim for untimely filing if 
the receipt date applied to the claim exceeds 12 months or 1 calendar year from the date the services were 
furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed until February 22, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic appliance (E0673) provided on December 14, 
2021. 
 
You asked the Plan to pay for a pneumatic appliance. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical equipment 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
  The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for a pneumatic appliance (E0673) provided on December 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for and pay for pacemaker surgery and self-
administered drugs provided from March 3, 2022, to March 4, 2022. 
 
You asked the Plan to waive the copayment for and pay for pacemaker surgery and self-administered drugs. 
You say that you are on a fixed income. The Plan denied your request. The Plan says the copayment amount 
you are being charged is correct. The Plan also says that the denial of payment for self-administered drugs is 
correct, because these drugs are not covered by your Medicare Part B prescription drug benefits. 
 
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 $345 
copayment for outpatient surgery at an outpatient hospital. The rules say that Medicare Part B generally does 
not pay for self-administered drugs. 
 
You have been asked to pay $345 copayment for pacemaker surgery. Pacemaker surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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. Additionally, the self-administered drugs billed on this claim are not covered by Medicare Part B 
benefits. Therefore, we decided that the Plan does not have to waive the copayment for and pay for pacemaker 
surgery and self-administered drugs provided from March 3, 2022, to March 4, 2022.  
 
Benefits for pacemaker surgery and self-administered drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an out-of-network (OON) specialist office 
visit provided on October 13, 2021. 
 
You asked the Plan to reduce the copayment for the OON office visit. You say that the service should be 
processed as in-network with a $35 copayment. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 $70 
copayment for specialist services with an out-of-network provider.  
 
 
 
 
 
 
 The file shows that the Plan verified the provider is not a network provider. Therefore, you have been asked to 
pay a $70 copayment for the OON office visit. The OON office visit falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits 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 reduce the copayment 
for an out-of-network (OON) specialist office visit provided on October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 21, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on April 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdualag. 
 
You asked the Plan to pre-approve Opdualag. 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 Opdualag. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found 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. No literature from Medicare approved cancer journals were submitted for review. The elements of the 
coverage criteria are not satisfied.  The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdualag have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Opdualag.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the computed tomography, of the heart, 
with contrast material (75572) and the computed tomography, of the thorax, diagnostic; without contrast 
material (71250) provided on July 20, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the services provided. 
 
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 up to $75 per day for Medicare-covered diagnostic radiology services.  
 
 You have been asked to pay $66.73 ($41.44 + $25.29) for the Medicare-covered diagnostic radiology services 
provided. This includes the Plans allowed amount of $207.19 x 20% coinsurance=$41.44 for the computed 
tomography of the heart. Additionally, this includes the Plans allowed amount of $126.45 x 20% 
coinsurance=$25.29 for the computed tomography of the thorax. The Plan contract says that you must pay a 
20% coinsurance up to $75 per day for Medicare-covered diagnostic radiology services. 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 coinsurance for the computed tomography, of the heart, with contrast material 
(75572) and the computed tomography, of the thorax, diagnostic; without contrast material (71250) provided 
on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary (upper) denture. 
 
You asked the Plan to pre-approve a complete maxillary denture. You say that your dentures have broken. The 
Plan denied your request. The Plan says that this request 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 Plans coverage rules apply in this case. The Plan covers a complete 
maxillary denture once every five years.  
 
We looked at the file and Plan rules. The file indicates you were covered for a complete maxillary denture on 
January 14, 2021, which is less than five years ago. Based on this information, we decided that the Plan's rules 
for coverage of a complete maxillary denture have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a complete maxillary (upper) denture.
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 July 
17, 2020, to July 23, 2020. 
 
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 the provider has reported inpatient hospital services with the incorrect DRG. 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 DRG 689 (KIDNEY AND URINARY TRACT 
INFECTIONS WITH MCC). 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 services. Our 
reviewer says that the services at issue in this case were not supported by the medical records Our physician 
reviewer found that a nephrology consultation was not found in the record. While the patient was documented 
to receive a "bolus" in the ED, this was described as associated with infection and no provider documentation 
that this was to address significant renal dysfunction was found. The review has determined that N17.0 - Acute 
kidney failure with tubular necrosis - was not a valid diagnosis for this case. The records support DRG 690.  
 
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 July 17, 2020, to July 23, 2020.