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

 
We decided that the Plan does not have to pre-approve treatment with pegfilgrastim (J2506). 
 
You asked the Plan to pre-approve pegfilgrastim. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical-necessity rules have not been met because the 
requested drug has been prescribed for an off-label and not medically accepted use. 
 
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 pegfilgrastim. Our reviewer says that 
the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that 
the requested use of pegfilgrastim is not FDA-approved for the enrollees diagnosis. Furthermore, the use is not 
supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved 
medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pegfilgrastim have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with pegfilgrastim (J2506).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not met 
the step therapy criteria. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary in this case. Our physician reviewer found that provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred 
step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Hyaluronan intra-articular injection 
provided on March 11, 2022. 
 
You asked the Plan to waive the copayment for a Hyaluronan intra-articular injection. You say that you were 
never told you'd have this large cost-sharing amount, and feel it is unfair. You cannot afford this large bill. The 
Plan denied your request. The Plan says the coinsurance that was applied was correct. 
 
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 all Medicare Part B chemotherapy drugs and other Part B drugs (injections). The allowed 
amount of this drug is $1377 resulting in a $275.40 coinsurance ($1377 x 20% = $275.40).  
 
You have been asked to pay a $275.40 coinsurance for a Hyaluronan intra-articular injection. a Hyaluronan 
intra-articular injection falls within Medicare Part B Prescription Drugs 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 a Hyaluronan intra-articular injection provided 
on March 11, 2022.  
 
Your complaint about the pain management staff not giving you the information about the coinsurance is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology visits provided on March 14, 2022, and April 
11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmology visits. You say that you were told if you use your 
Ophthalmologist, you would be reimbursed. The Plan denied your request. The Plan says the service can be 
provided by an in-network provider. 
 
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 ophthalmology visits provided on March 14, 2022, 
and April 11, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on September 30, 2021. 
 
You asked the Plan to pay for telehealth services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for telehealth services provided on September 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic repetitive transcranial magnetic stimulation 
(rTMS) treatment (90867). 
 You asked the Plan to pre-approve rTMS treatment. You say that the requested treatment is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for the requested 
treatment have not been met. 
 
The Plan follows Medicare rules. The rules say that rTMS is considered medically necessary when the criteria 
listed in the Medicare rules section of this letter have been met. 
 
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 rTMS treatment. Our reviewer says that 
the requested service is not medically reasonable and necessary in this case. Our physician reviewer found that 
there is no documentation of the enrollee undergoing an adequate trial of psychotherapy for the treatment of 
depression. There is also no documentation of the enrollee being tried on medication as is required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rTMS treatment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve therapeutic repetitive transcranial magnetic stimulation (rTMS) treatment (90867).
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 (K0861) and attachments. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options and attachments. 
You say that these services are medically necessary. The Plan denied your request. The Plan says that you have 
no current pressure ulcer, no history of pressure ulcers and no history of flap surgery. 
 
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 Group 3 power wheelchair with 
multiple power options and attachments. Our reviewer says that the requested services are not considered 
medically reasonable and necessary in this case. Provided records do not support that you are high risk for skin 
breakdown. You are currently using an electric wheelchair and have no ulcers or a history of pressure ulcers or 
skin flap surgery. Records do not document that you perform bladder self-catheterization and are unable to 
transfer independently or that you have increased muscle tone or spasticity, thus you do not meet criteria for the 
power tilt/recline or the multiple power options. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 a Group 3 power wheelchair with multiple power options and attachments 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 (K0861) and attachments.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits from May 28, 
2021, to July 9, 2021. 
 
You asked the Plan to waive the copayments for physical therapy visits. You say that you feel this service 
should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 Medicare-covered physical therapy visit.  
 
You have been asked to pay a total of $270 for physical therapy visits ($30 copayment x 9 visits = $270). 
Physical therapy visits fall within the Outpatient Rehabilitation 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 copayments for physical therapy visits from May 28, 2021, to July 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography services coded 75710-59 provided on April 
13, 2022. 
 
You asked the Plan to pay for the angiography services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this code is considered inclusive to 
another billed code and no separate payment is due. 
 
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 code 75710 is a column II code to column I code 37225; however, 75710 
was billed with a modifier.  
 
We asked our coder 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 angiography services. Our reviewer says that the 
documentation does not support payment for the angiography services coded 75710-59. Our reviewer found the 
documentation does not support the use of procedure code 75710. The code description within procedure code 
37225 includes the angiography services which were performed on the same side. There is no support for the 
use of the 59 modifier to bypass the NCCI edit. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the angiography services have not been met. Therefore, we decided that the 
Plan does not have to pay for the angiography services coded 75710-59 provided on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 30, 2022. 
 
You asked the Plan to pay for home health services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for home health services provided on May 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you don't have the ability to administer your own 
medications. The Plan denied your request. The Plan says you do not meet the criteria for skilled nursing 
facility admission. 
 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your care needs, custodial and intermittent, can be provided at a lower level of care. 
You do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our reviewer also found that you do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73610 billed for date of service  
May 14, 2022. 
 
You asked the Plan to pay for procedure code 73610. The Plan denied your request. The Plan says payment for 
code 73610 is bundled into payment for code 99283. 
 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 code 73610 
is a column II code to column I code 99283. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 73610 billed for date of service May 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable with complex 
comorbidities and will require LTAC hospital admission for six weeks. The Plan denied your request. The Plan 
says admission to LTACH was denied as not meeting criteria, is not medically necessary, and continued acute 
hospital stay was offered, until the enrollee could discharge to a lower level of care. 
 
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 the enrollee appears to be stable and improving and should only require short term 
additional acute care hospital services that can safely be administered at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
 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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX. 
 
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 the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have a diagnosis of right hand and 
left wrist primary osteoarthritis. There is limited peer-reviewed medical literature that supports the use of 
Supartz FX for the treatment of hand/wrist osteoarthritis. The services are not safe and effective 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this was an emergency, 
and you required an ambulance to get to the hospital The Plan denied your request. The Plan says you were 
charged this cost sharing 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 each ambulance trip. You had one ambulance trip(s). The Plan charged you $150 for these 
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 copayment for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 20, 2022 billed with 
codes 81317, 81292, 81298, 81295, 81300, 81297, 81219, and 81294. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the testing was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 20, 2022 billed with codes 81317, 81292, 81298, 81295, 81300, 81297, 81219, and 81294.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the heart with 
quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve the services. You say that you were unable to complete previous stress tests 
and require additional testing. The Plan denied your request. The Plan says the requested service is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 services. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that you are 
asymptomatic from a cardiovascular standpoint according to the physician. Overall, there is insufficient support 
in the peer-reviewed literature demonstrating a significant benefit of CT imaging of the heart with quantitative 
evaluation of coronary calcium in guiding optimal management for you. As such, CT imaging of the heart 
without contrast material with quantitative evaluation of coronary calcium is considered experimental and 
investigational for the evaluation and management of your medical condition. The current evidence for this 
service in asymptomatic individuals is limited and inconclusive. 
 
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 computed tomography (CT) of the heart with quantitative evaluation of coronary calcium 
(75571).