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

 
We decided that the Plan does not have to pay for the MammaPrint testing provided on April 6, 2022. 
 
You asked the Plan to pay for the testing services. You say that Medicare allows and pays for the code when 
billed for MammaPrint. The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 
 We looked at the file and the rules. We find that the testing is not supported. Specifically, the records do not 
show that the enrollee has early-stage breast cancer. Based on this information, we decided that Medicare rules 
for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay 
for the MammaPrint testing provided on April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement Continuous Positive Air Pressure (CPAP) 
machine (E0470). 
 
You asked the Plan to pre-approve the replacement CPAP machine. You say that the replacement is medically 
necessary. Your CPAP has been recalled and a replacement has not been provided. The Plan denied your 
request. The Plan says the manufacturer is providing a replacement CPAP under a manufacturer's recall. 
 
The Plan must follow Medicare rules. Medicare rules say that Payments for repair and maintenance may not 
include payment for parts and labor covered under a manufacturers or suppliers warranty. 
 
We looked at the file and Medicare rules. The existing CPAP machine is not eligible for replacement as it is 
less than 5 years old. The equipment is covered under warranty and the manufacturer is noted to be providing a 
replacement due a to a recall. Based on this information, we decided that Medicare rules for coverage of the 
replacement CPAP machine have not been met. Therefore, we decided that the Plan does not have to pre-
approve a replacement Continuous Positive Air Pressure (CPAP) machine (E0470).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria. 
 
You asked the Plan to pre-approve Simponi Aria. You say that the enrollee needs to be on the requested 
medication because he is suffering with chronic neck pain with Kyphosis bulky Osteophytes. The Plan denied 
your request. The Plan says the requested drug is non-preferred, and that the enrollee has not tried any of the 
preferred agents. The Plan says that the provider has not supplied a rationale for use of the non-preferred 
product for safety or efficacy.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Simponi Aria. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drugs 
Humira, Enbrel, Xeljanz, Xeljanz XR or Rinvoq before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the 
Plans required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi (CPT code J9173). 
 
You asked the Plan to pre-approve the medication. You say that the medicine is mediclaly necessary for the 
enrollee. The Plan denied your request. The Plan says the use of this drug/regimen is not reasonable and 
necessary. The Plan states the standards that need to be met are: The accepted use of this drug for the enrollee's 
condition requires: stage II or III disease; therefore, the standards do not appear to be 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 the medication. Our physician reviewer 
found the FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Imfinzi (CPT code J9173).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the pelvis (72197). 
 
You asked the Plan to pre-approve an MRI of the pelvis. You say that new medical records have been 
submitted to show medical necessity. The Plan denied your request. The Plan says that the MRI is not 
medically necessary per Medicare criteria for coverage. 
 
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 an MRI of the pelvis. Our reviewer says 
that the service is medically necessary. Our physician reviewer found the enrollee has urethral stricture disease, 
neurogenic bladder and elevated PSA of 5.95 ng/mL. The current standard of care as per AUA guidelines is as 
follows, in men who have been found to have an elevated PSA, after a shared decision-making process, if they 
elect to proceed with a prostate biopsy, there is now data to support that they should undergo an MRI prior to 
their initial biopsy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the pelvis have been met. Therefore, we decided that the Plan has to 
pre-approve an MRI of the pelvis (72197).  
 
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 Cyramza (J9308) to be used in combination with 
Diphenhydramine (J1200). 
 
You asked the Plan to pre-approve Cyramza to be used in combination with Diphenhydramine. You say that 
this drug regiment is medically necessary for the enrollee. The Plan denied your request. The Plan says the use 
of this drug/regimen is not reasonable and necessary. The Plan also says that the accepted use of this drug 
requires alpha feta protein greater than or equal to 400ng/mL, and the standards do not appear to be 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 Cyramza to be used in combination 
with Diphenhydramine. Our reviewer says that the elements of the coverage criteria are not satisfied, and the 
requested service cannot be recommended. 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. Our reviewer also found that no literature from Medicare approved cancer journals were submitted 
for review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cyramza to be used in combination with Diphenhydramine have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Cyramza (J9308) to be used in combination 
with Diphenhydramine (J1200).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation for future appointments. The Plan denied your request. The Plan says this service is covered 
under your benefit package, but exceeds the maximum count allowed per period. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs to group 3 power wheelchair 
(K0861). 
 
You asked the Plan to pre-approve power wheelchair repairs. You say that you do not feel that this is misuse 
since this is the only way you can get around. After 8 months the tires have worn out and you need tires and is 
using a borrowed joystick. The Plan denied your request. The Plan says the repairs do not meet the medically 
necessary criteria as the needed repairs do not appear to be from normal wear and tear. 
 
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 patients condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair repairs. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the damage to the wheelchair indicates extensive use beyond household use for 
mobility activities of daily living. The power wheelchair is not intended for use outside the home. Flat worn 
tires within 6-8 months indicates extensive use outside the home. Per Medicare rules for power wheelchairs 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair repairs have not been met. Therefore, we decided that the 
Plan does not have to pre-approve power wheelchair repairs to group 3 power wheelchair (K0861).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the radiology services and a specialist 
office visit provided on May 26, 2021. 
 
You asked the Plan to waive the copayments for the radiology services and a specialist office visit. You say 
that you would like to know if the copayments applied are correct or not. The Plan denied your request. The 
Plan says the proper copayments were applied for the services that were rendered. 
 
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 $250 
copayment for Medicare-covered diagnostic radiology services (other than x-rays) at a freestanding or 
outpatient facility and a $50 copayment for each Medicare-covered specialist visit. 
 
  You have been asked to pay a $250 copayment for the radiology services and a $50 copayment for the 
specialist office visit. The radiology services fall within the Outpatient Diagnostic Tests and Therapeutic 
Services benefit category. The specialist office visit falls within the Physician/Practitioner Services, Including 
Doctors 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 waive the copayments for the 
radiology services and a specialist office visit provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you have multiple injuries to both 
of your ankles. You state that you have been seeing this doctor for several years and you need to continue to 
see him. The Plan denied your request. The Plan says your records received do not indicate that you have an 
emergent or urgent medical condition, or are in need of specialized service(s) that are not available in the 
network. The Plan states there are in-network provider(s) within a reasonable distance from your location that 
can provide this service or item. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office services to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided January 5, 2022, to 
January 13, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee met criteria for inpatient 
level of care. The Plan denied your request. The Plan says you needed to be in a hospital but could have been 
seen as an observation patient. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee had stable vital signs on admission and mental status was at 
baseline. Evaluation revealed no sign of infection; computed tomography (CT) scans of the head and cervical 
spine were normal. X-rays were negative for fracture. The enrollee was admitted and evaluated by physical 
therapy, occupational therapy, and palliative. The enrollee was felt appropriate for skilled nursing facility 
placement. The enrollee did not require or receive any inpatient diagnostic studies or therapeutic interventions. 
The record did not show that at the time of inpatient admission the admitting physician reasonably expected 
that the enrollee's necessary hospital care (including earlier emergency departed 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 not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided January 5, 2022, to January 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve the group 3 power wheelchair with multiple power options. You say that 
this chair and features are medically necessary. The Plan denied your request. The Plan says coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that if a Group 3 Single Power Option or Multiple Power 
Options Power wheelchair is provided and if coverage criteria is not met, it will be denied as not 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 the group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested power wheelchair is not medically necessary. Our 
physician reviewer found the clinical documentation does show that patient has diagnosis that is qualifying for 
group 3 power chair and would not be functionally appropriate for cane, walker or manual wheelchair however, 
there is no documentation to show that the patient is incapable of pressure relieving, so the power options 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 the group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple 
power options.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member can adequately receive the care needed for 
ongoing management in the current location. 
 
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. The patient 
appears to still be unstable and requires additional acute care services that can safely be administered at the 
current facility until more stable for transfer. The patient does not require services at the LTACH that are not 
already available at the current facility. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the surgery. You say that the service is necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary cancer screening provided to the enrollee on 
November 8, 2021. 
 
You asked the Plan to pay for the screening. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the 
physician who is treating the beneficiary for the purpose of early detection of cardiovascular disease in 
individuals without apparent signs or symptoms of cardiovascular 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 pay for the screening. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the test is described as a genetic based cardiovascular risk factor screening test in which multiple genes are assessed using genomic DNA extracted from patient sampling. It assesses the presence of pathogenic 
or likely pathogenic variants in genes known to be associated with increased cardiac risk. It is not a diagnostic 
test. There is no evidence to support its role in this patient clinical management. In summary, the requested 
testing is not considered 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 the screening have not been met. Therefore, we decided that the Plan does not 
have to pay for hereditary cancer screening provided to the enrollee on November 8, 2021.