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

 
We decided that the Plan does not have to waive the copayment for surgical procedure provided on November 
19, 2021. 
 
You asked the Plan to waive the copayment for surgical procedure. You say this procedure was because of 
sores that you had received due to elder abuse. This was very inconvenient to have to go every week to have 
them taken care of so this 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 $250 
copayment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical 
center, including but not limited to hospital or other facility charges and physician or surgical charges. 
 
 You have been asked to pay $250 copayment for surgical procedure. Surgical procedures fall within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for surgical procedure 
provided on November 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PT to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve PT. You say that you need these services done by the requested provider. 
The Plan denied your request. The Plan says the plan will not cover care from a provider who does not work 
with the health plan and there are in-network providers within 6.7 miles of you accepting new patients. 
 
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 
physical therapy (PT) to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
met. 
 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 Ilumya. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Stelara before they will approve the requested drug, Ilumya. There is no indication that 
the enrollee has tried and failed the required drug. Based on the medical records provided and the Medicare-
approved drug compendia, there is no indication that the Plan's required drug would likely be less effective 
and/or likely have adverse effects for the enrollee. You argue that Stelara is not appropriate as it is self-
administered (subcutaneous); the requested Ilumya is also a subcutaneous medication. There is nothing in the 
prescribing information for Stelara that says it cannot be given by a healthcare provider as Ilumya is. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Ilumya (J3245).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient surgery provided on March 2, 
2022. 
 
You asked the Plan to waive the coinsurance for outpatient surgery. You say that you should only be charged a 
$120 copayment. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for surgery performed at an outpatient hospital facility.  
 
You have been asked to pay $453.57 which is 20% of the allowed amount for outpatient surgery. The allowed 
amount is $2,267.83 (20% x $2,267.83= $453.57). Outpatient surgery falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for outpatient surgery provided on March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care (99291) provided on February 4, 2022. 
 
You asked the Plan to pay for critical care (99291). You say that the attached medical record contains the 
detailed account history, examination and medical decision making provided. You say that the documentation 
supports the evaluation and management level of care billed and the code is payable as billed. The Plan denied 
your request. The Plan says the medical records submitted don't include a critical care evaluation and 
management note supporting 30-74 minutes of critical care. 
 
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, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
 
  We find that CPT code 99291 is not supported in the medical record. Specifically, the medical records do not 
document the time spent on evaluation and management services as required by the CPT code billed. Based on 
this information, we decided that Medicare rules for coverage of critical care (99291) have not been met. 
Therefore, we decided that the Plan does not have to pay for critical care (99291) provided on February 4, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from January 17, 2022, 
to January 20, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that none of the drugs you received were 
self-administered, as they were prescribed by the hospital, or they were medications normally administered by 
your nursing home. The Plan denied your request. The Plan says self-administered drugs are not covered while 
you are in the hospital. The Plan also says that you are responsible for this amount. 
 
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 from January 17, 2022, to January 20, 2022.  
 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on July 3, 2021. 
 
You asked the Plan to waive the copayment for ER visit. You say that no services were provided at the hospital 
and that they were very unprofessional so it 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay $90 copayment for ER visit. ER visits fall within the Emergency 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 ER visit provided on July 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six additional acupuncture visits. 
 
You asked the Plan to pre-approve acupuncture. You say that the requested additional visits are essential for 
pain management. The Plan denied your request. The Plan says Medicare requires that the provider be either a 
Doctor of Medicine (MD), Physician Assistant (PA) or Nurse Practitioner (NP) and the provider you wish to 
see, does not have that licensure. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider must be either an MD, PA, or nurse 
practitioner. Therefore, we decided that the Plan does not have to pre-approve six additional acupuncture visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eligard (J9217). 
 
You asked the Plan to pre-approve Eligard. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition by Medicare Part B. The Plan also says that it has been indicated that this 
drug is being dispensed by a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Eligard (J9217).  
 
Benefits for Eligard 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo, Yervoy, Abraxane, and Carboplatin. 
 
You asked the Plan to pre-approve the requested drugs. You say that the drugs are approved for stage 4 
systemic treatment. The Plan denied your request. The Plan says the clinical effectiveness of the regimen with 
disease progression has not been demonstrated. 
 
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 requested drugs. Our physician 
reviewer found that the enrollee has stage IIIB squamous cell carcinoma non-small cell lung cancer. The 
requested use of the drug regimen is not FDA-approved for the enrollee's diagnosis. The enrollee has 
progressed on prior immunotherapy. The requested use is not supported by one of the major drug compendia or 
by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not 
supported or not recommended in any of the compendia. The documentation does not support that the 
requested drug is safe and effective and otherwise reasonable and 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 requested drugs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Opdivo, Yervoy, Abraxane, and Carboplatin.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous basivertebral nerve ablation 
procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's pain is disabling. The 
Plan denied your request. The Plan says the procedure is considered unproven. 
 
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 requested services. Our physician 
reviewer found that the Intracept procedure remains experimental. More research is needed to show safety and 
efficacy. Therefore, the request is not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous basivertebral nerve ablation procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skin substitute graft. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee's wound is infected. 
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic venous hypertension (idiopathic) with ulcer of his left lower 
extremity. His medical history is notable for type 2 diabetes, for which he takes Metformin and NovoLOG 
insulin. He is a current every day smoker. He was evaluated for a possible infection of his leg wound. The 
wound measured 13x3.5 cm which was slightly larger than it was on July 5, 2022. He had a dry black eschar 
base and green/yellow tenacious eschar peripherally. The physician documents that the wound does not seem to 
have infection, but still had significant necrotic tissue, looked worse, and was not satisfactorily cleaning up. 
The enrollee was treated for infection with Augmentin several weeks earlier. Santyl was used for enzymatic 
debridement. The documentation does not support that a skin graft substitute is medically reasonable and 
necessary for the enrollee in this case. It is not documented that the enrollee's blood sugar is adequately 
controlled. In addition, the enrollee continues to smoke. 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a skin substitute graft.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet the criteria for SNF care and the services you require is 
intermittent therapy, which can be safely received in a different setting, such as at home with home health. 
 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 that 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. 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 skilled nursing facility (SNF) care.
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 enrollee has already been to a skilled nursing 
facility, which is where the enrollee got worse and now has bed sores. The Plan denied your request. The Plan 
says based on Medicare guidelines and the information they have received; the enrollee does not meet the 
requirements. 
 
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 does not require the intensity of services provided at an IRF. Our physician reviewer also found that the enrollee is not shown to require or currently to be able to perform 15 
hours per week of rehabilitative services with regular physician evaluation. Our physician review also found 
that the enrollee's care needs can be met at a lower level of care. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dialysis services. You say that you want to continue receiving dialysis 
services from the out-of-network provider. The Plan denied your request. The Plan says rules for coverage for 
out-of-network care have not been met. 
 
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 
dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis (L1906) and heel stabilizer, 
prefabricated, off-the-shelf (L3170) provided February 18, 2022. 
 You asked the Plan to pay for the orthosis. You say that the enrollee's primary care physician prescribed this 
brace within 6 months of the face to face visit. Medicare would have paid this claim and the Plan needs to pay 
as well. The Plan denied your request. The Plan says the records do not support the billed service. 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the record indicates that the enrollee has ankle and foot pain form osteoarthritis. 
The provided records do not document the need for stabilization of the ankle or foot for medical reasons. The 
elements of the coverage criteria 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 the orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the ankle foot orthosis (L1906) and heel stabilizer, prefabricated, off-the-shelf (L3170) 
provided February 18, 2022.