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

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says coverage for this requested drug may be provided through a Medicare Part D
(prescription drug) benefit.
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 the services. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found chronic inflammatory
demyelinating polyneuropathy (CIDP) is not a covered diagnosis for treatment of in-home intravenous
immunoglobulin (IVIg) infusion therapy under Part B benefits. The review indicates that the documentation
does support that the requested drug is medically reasonable and necessary for the enrollee. The documentation
does support that the requested drug is safe and effective 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Gamunex-C solution 2.5mg/25ml solution for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the moderate sedation services (99152), 
the inpatient hospital care, per day (99223), and the hospital discharge day management (99238) provided on 
May 3, 2021 and May 7, 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 for each Medicare-covered 
hospital stay. Inpatient hospital care is covered which includes inpatient acute, inpatient rehabilitation, long-
term care hospitals, and other types of inpatient hospital services and physician services.  
 
You have been asked to pay $54.72 (the Plan allowed amount of $273.60 x 20% coinsurance) for the inpatient 
physician services provided. 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 moderate sedation 
services (99152), the inpatient hospital care, per day (99223), and the hospital discharge day management 
(99238) provided on May 3, 2021 and May 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says outpatient treatment might be able to be approved. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found based on a 
review of the records provided, it was not expected that this enrollee would improve in a reasonable period of 
time beyond the dates in question. The enrollee was not showing any dangerousness to self or others, and did 
not report auditory or visual hallucinations. There are no aggressive behaviors or acute threats to safety. The 
enrollee was cooperative and compliant with medication. It did not appear medically necessary and reasonable 
to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the 
dates in question. The health plan's denial of continued inpatient psychiatric services appears appropriate. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to an inpatient psychiatric facility for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound dressing provided on May 6, 2021.
You asked the Plan to pay for the wound dressings. You say that the records support the billed items. The Plan denied your request. The Plan says no proof of delivery was provided despite multiple requests.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The appeal was
submitted with an order. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the wound dressing provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation beyond the 52 allowed 
trips. 
 
You asked the Plan to pre-approve additional trips. You say that you have various important appointments. 
You say that you have had to cancel some because you do not have anyone to take you. You also say that you 
do not know how to drive. The Plan denied your request. The Plan says 52 one-way trips are covered for the 
year. The Plan also says that additional trips beyond the 52 are not covered. 
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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of 52 one-way 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 beyond the 52 allowed 
trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (88341, 88342) provided on July 14, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
88341 and 88342 are column II codes to column I code 88360. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (88341, 
88342) provided on July 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $250 copayment charged for ambulance transport 
provided on January 15, 2021. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment is a contractual obligation based on the service 
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 $250 
copayment for ambulance transport. 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 $250 copayment charged 
for ambulance transport provided on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment 
supported porcelain/ceramic crown (D6058) provided on May 6, 2021. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain/ceramic 
crown. You say that you would like to appeal these services. The Plan denied your request. The Plan says these 
services are not covered benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on 
May 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on February 13, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the doctor advised
that you would not need to be transported to the hospital. The Plan denied your request. The Plan says if you
refuse transport when an ambulance is dispatched, you will be responsible for the full cost of the service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on February 13, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
(A0998) provided on February 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement services provided at an 
outpatient hospital facility on June 8, 2021. 
 
You asked the Plan to waive the copayment for the wound debridement services. You say that your husband's 
leg is not healing from the original surgery and you don't think it is fair that you have had to continue to pay 
copayments for the same problem. The Plan denied your request. The Plan says this copayment 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $200 copayment for outpatient surgery and services at an outpatient hospital.  
 
The enrollee has been asked to pay a $200 copayment for the wound debridement services. The wound 
debridement services fall within the outpatient surgery and services at an outpatient hospital benefit category. 
This copayment applies regardless of the reason for the services.  This means that the enrollee has been asked 
to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for wound debridement services provided at an outpatient hospital facility on June 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the spinal 
canal (72141). 
 
You asked the Plan to pre-approve the MRI of the spinal canal. You say that you would like reconsideration 
because the member has completed physical therapy and has been seen by the provider since. The Plan denied 
your request. The Plan says the member has not completed physical therapy. 
 
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 spinal canal. Our 
reviewer says that the records did not clearly show that the member had recently fully exhausted and failed 
conservative treatments to help justify imaging at this time. Our physician reviewer found there were no recent 
physical examination findings showing evidence of a likely red flag diagnosis to justify bypassing a full trial of 
conservative treatments. 
 
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 spinal canal have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the spinal canal (72141).
Appeal type: Practitioner Services
Decision: Favorable

We decided the Plan has to pay for out of network physician services provided on April 13, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says that as an HMO plan, Medicare rules permit them to redirect members through their 
physician to coordinate care. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  The Plan contract submitted with the case file is for the PPO 
Plan product and states enrollees can use out of network providers without prior authorization. The Plan did not 
send a Plan contract that supports their denial as an HMO restriction. Therefore, we decided that the Plan has to 
pay for out of network physician services provided to the enrollee on April 13, 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for behavioral health services (99214, 90833) 
received on April 8, 2021, and June 3, 2021. 
 
You asked the Plan to waive the copayment for mental health services. You say that the services should be 
covered. The Plan denied your request. The Plan says the copayment 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 
copayment for each Outpatient mental health care visit.  
 
You have been asked to pay a $60 copayment for mental health services. Mental health service falls within the 
Outpatient mental health 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 behavioral 
health services (99214, 90833) received on April 8, 2021, and June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for combined electrochemical treatment (CET), including electrical nerve stimulation with the Sanexas device, neuromuscular reeducation, vasopneumatic treatment, and nutripharmaceutical injections, provided on December 2, 2020.
You asked the Plan to pay for CET procedures. You say that the requested services were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
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 CET procedures. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that, based on the provided documentation, the above items/services were not supported and will be considered not medically necessary for the following reasons: there was no record of a nutrient deficiency (vitamin B12 or otherwise) to justify nutripharmaceutical injections. There was no direct physical examination findings documented showing significant edema to justify the vasopneumatic treatment. There is insufficient evidence to support the use of the Sanexas neurostimulation device for diabetic neuropathy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CET procedures have not been met. Therefore, we decided that the Plan does not have to pay for combined electrochemical treatment (CET), including electrical nerve stimulation with the Sanexas device, neuromuscular reeducation, vasopneumatic treatment, and nutripharmaceutical injections, provided on December 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for prostate biopsy, colonoscopy, and inguinal hernia repair.
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says there are no serious medical problems that requires monitoring in the hospital after surgery.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record indicates that the enrollee is scheduled for a prostate biopsy, colonoscopy, and inguinal hernia repair. The record does not document the medical necessity for the admission or why the requested procedures cannot be arranged as an outpatient. The elements of the coverage rule are not satisfied. 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 pre-approve an inpatient admission for prostate biopsy, colonoscopy, and inguinal hernia repair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin (J9045), Paclitaxel (J9267), and supportive 
medications. 
 
You asked the Plan to pre-approve the Carboplatin, Paclitaxel, and supportive medications. You say that you 
need these drugs to keep you alive. The Plan denied your request. The Plan says the off-label use of this 
regimen for your condition is not medically accepted per Medicare rules and is not covered based on available 
information. 
 
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 Carboplatin, Paclitaxel, and 
supportive medications. Our reviewer says that the elements of the coverage criteria are not satisfied. Our 
physician reviewer found the record indicates that you have a diagnosis of malignant mesothelioma. The record 
indicates that the planned treatment is Carboplatin/Alimta. The Plan has indicated that this combination is 
indicated for the noted diagnosis. Our reviewer found that the Food and Drug Administration (FDA) has not 
stated that the requested drug is indicated for your condition. The Medicare approved cancer drug compendia 
do not contain a supportive citation for the use of the requested drug in your clinical situation. 
No literature from Medicare approved cancer journals were submitted for review. Our physician reviewer also 
found that the record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. 
 
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 Carboplatin, Paclitaxel, and supportive medications have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Carboplatin (J9045), Paclitaxel (J9267), and 
supportive medications.  
 
Please Note: The record shows that Alimta was the planned treatment, however, the authorization request and 
denial was for Paclitaxel. This decision is solely regarding the requested/denied regimen of Carboplatin and 
Paclitaxel. You may wish to submit a new request for the intended drugs directly to the Plan for consideration.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a home blood pressure monitor. 
 
You asked the Plan to provide coverage for a home blood pressure monitor. You say that this device is 
medically necessary to monitor your blood pressure. The Plan denied your request. The Plan says this device is 
not covered by Medicare unless you are on home dialysis. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis. The records do not show that this monitor is requested in the setting of 
home dialysis services. Although monitoring blood pressure in the home may be appropriate in this case, 
neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the 
Plan does not have to provide coverage for a home blood pressure monitor.