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

 
We decided that the Plan does not have to pre-approve ondansetron. 
 
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 ondansetron.   
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
September 09, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that this should have been a 
preoperative appointment only. 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 $150 
copayment for outpatient hospital services, including lab tests. 
 
You have been asked to pay a $150 copayment for the laboratory services. This item/service falls within the 
outpatient hospital services, including lab tests 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. However, since the allowed amount is less than the standard 
copayment, you only owe $121.80. Therefore, we decided that the Plan does not have to waive the copayment 
for the laboratory services provided on September 09, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0425 and A0427) provided on 
January 26, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary due 
to being unconscious and unable to walk. The Plan denied your request. The Plan says based on the records 
received, you did not show any symptoms that would require intervention and ambulance support during 
transportation. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our physician 
reviewer found transportation via ambulance to the emergency department was not medically necessary. You 
did not require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport. Transportation could have been provided by other means (stretcher van, wheelchair 
van, private car, taxi) without endangering your condition. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance services (A0425 and A0427) provided on January 26, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility. 
 
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 a subarachnoid hemorrhage. The enrollee's medical 
problems are stable, and 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on September 13, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on September 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a PET scan provided on October 6, 2022. 
 
You asked the Plan to waive the cost share for a PET scan. You say that you feel you should not be responsible 
for the cost share of the contrasting agent required for a PET scan. 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 20% 
coinsurance for each Medicare-covered medical supply and a $130 copayment for Medicare-covered 
radiological diagnostic services.  
 
 You have been asked to pay a total cost share of $1,081.78 for a PET scan. The total includes $951.78 
coinsurance ($4,758.88 allowed x 20% = $951.78) and a $130 copayment for Medicare-covered radiological 
diagnostic services. This item/service falls within the outpatient diagnostic tests 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 cost share for a PET scan provided on October 6, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (Guardant360 CDx) provided on January 5, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that this test was medically necessary and 
appropriate. The Plan denied your request. The Plan says that this test is experimental and was not medically 
necessary for this enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found at progression, the National Comprehensive Cancer Network (NCCN) Guidelines 3.2023 
recommends considering plasma and/or tissue-based testing using broad molecular profiling for genomic 
resistance mechanisms. Per the NCCN guidelines, there is growing recognition of the molecular mechanisms of 
resistance to therapy. Re-testing of a sample from a tumor that is actively progressing while exposed to targeted 
therapy can shed light on appropriate next therapeutic steps. The use of Guardant360 was reasonable and 
medically necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have been met. Therefore, we decided that the Plan has 
to pay for the laboratory services (Guardant360 CDx) provided on January 5, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiac ultrasound provided on 
November 28, 2022. 
 
You asked the Plan to waive the copayment for the cardiac ultrasound. You say that this should only have a 
$35 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 $170 
copayment for in-network outpatient diagnostic radiology services. 
 
You have been asked to pay a $170 copayment for the cardiac ultrasound. This item/service falls within the in-
network outpatient diagnostic radiology 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 cardiac ultrasound provided on November 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
October 9, 2022, to October 22, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital. You say that you should have no cost 
sharing as this was in-network. 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 $125 
copayment per day for days 1-7 of each inpatient hospital stay.  
 You have been asked to pay a $125 copayment per day for days 1-7 of the inpatient hospital. These 
items/services fall within the inpatient hospital care benefit category. You have been asked to pay a total of 
$875 ($125 copayment per day x 7 days = $875). 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 inpatient hospital stay provided from October 9, 2022, to October 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on January 23, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that would like to have the claim 
reprocessed and paid. The Plan denied your request. The Plan says the services are not covered under your 
Medicare Part B plan. 
 
 
 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 pay for the self-administered drugs 
provided on January 23, 2023.  
 
Benefits for the 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
tooth #'s 6 and 10 (D6010). 
 
You asked the Plan to pre-approve the surgical placement of implant body: endosteal implant tooth #'s 6 and 
10. You say that your primary care provider says you need this procedure. 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 pre-approve a 
surgical placement of implant body: endosteal implant tooth #'s 6 and 10 (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system (L5981) and below-knee removable 
brim suspension (L5672). 
 
You asked the Plan to pre-approve a flex-walk system and removable brim suspension. You say that you 
disagree with the denial. The Plan denied your request. The Plan says that the records do not support that the 
enrollee has K3 functional status. 
 
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 a flex-walk system and removable brim 
suspension. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the documentation does not support that the enrollee 
is a K3 functional ambulator, therefore the requested components are not 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 a flex-walk system and removable brim suspension have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a flex-walk system (L5981) and below-knee 
removable brim suspension (L5672).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the chest, 
abdomen and pelvis. 
 
You asked the Plan to pre-approve the MRI of the chest, abdomen and pelvis. You say that the services are 
necessary to help your new doctor make a diagnosis of what is going on with your back and causing pain and 
sudden falls. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI of the chest, abdomen and 
pelvis. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found you had an 
MRI of the entire spine. This MRI has not been reviewed and commented on by the second opinion doctor. 
Repeat imaging at this time is not 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 the MRI of the chest, abdomen and pelvis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the chest, abdomen 
and pelvis.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lower extremity. 
 
You asked the Plan to pre-approve an MRI of the lower extremity. You say that your last surgery went wrong 
leaving you with a nerve pain that could affect your life. The Plan denied your request. The Plan says an MRI 
of the lower extremity is not medically necessary 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MRI of the lower extremity. Our 
reviewer says that the requested MRI of the lower extremity is not medically necessary. Our physician reviewer 
found that your physical exam revealed a painful scar plantar aspect right with no red flags. There were no 
conservative treatments initiated. The MRI is not indicated without a 6-week trial of physical therapy with 
evaluation of the efficacy afterward. There for the medical necessity of the exam has not been established in the 
records provided. 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the lower extremity have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the lower extremity.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit greatly from 
LTACH services. The Plan denied your request. The Plan says that the enrollee is receiving appropriate 
inpatient acute care and does not require transfer to a LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrolleee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively 
only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve the CardioMEMS procedure. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the CardioMEMS device is considered 
experimental/investigational, so this is 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 the CardioMEMS procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the CardioMEMS device was approved by the Food and Drug 
Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow 
measurement of pulmonary artery pressure in the management of patients with congestive heart failure. The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of 
CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
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 CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS procedure.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device services with the provider 
that were provided on October 27, 2022. 
 You asked the Plan to pay for the pneumatic compression device services with provider. You say that the Plan 
should reprocess and pay the claim. The Plan denied your request. The Plan says that the services should be 
billed directly to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the pneumatic compression device services with the provider 
that were provided on October 27, 2022.