Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro (daratumumab) treatments. 
 
You asked the Plan to pre-approve the Darzalex Faspro treatments. You say that it is felt that the requested 
drug is medically necessary. The Plan denied your request. The Plan says there is no evidence that the preferred 
drug could not be used. 
 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 the Darzalex Faspro treatments. Our 
reviewer says that the requested drug is not considered reasonable and necessary based on step therapy criteria. 
Our physician reviewer found the enrollee has a diagnosis of Multiple myeloma not having achieved remission. 
There is no evidence that the enrollee has tried the Plan-preferred drug, Velcade. The documentation does not 
support that Velcade would likely be less effective, and/or would likely have adverse effects for the enrollee in 
this case. 
 
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 Darzalex Faspro treatments have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Darzalex Faspro (daratumumab) treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
receiver (K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and receiver. You say that the enrollee would possibly fall into a 
coma due to having increased episodes and increased memory issues. The Plan denied your request. The Plan 
says the enrollee does not meet the requirements for approval for the requested supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a CGM and receiver have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
receiver (K0553, K0554).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service October 10, 
2021, to October 11, 2021. 
 
You asked the Plan to pay for procedure code S9500. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service October 10, 2021, to October 11, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tumor Origin testing provided on April 4, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says that a determination of medical necessity was not made as the DOS for lab 
tests must always be the date the sample was collected. 
 
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 testing at issue is a molecular pathology service provided by a non-blood 
bank. The sample taken was of a brain tumor. The Plan has not submitted evidence that this sample was not 
taken during an outpatient hospital encounter. As such, we find that the determination that the reported DOS is 
incorrect has not been supported. Therefore, we decided that the Plan has to pay for the Tumor Origin testing 
provided on April 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision of excess skin of the arms. 
 
You asked the Plan to pre-approve the skin excision procedure. You say that you feel that this surgery is 
needed to improve your quality of life. The Plan denied your request. The Plan says this is considered a 
cosmetic procedure, and it cannot be covered. 
 
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 skin excision procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the case file does not contain documentation that supports the medical necessity 
of the requested surgery. 
 
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 skin excision procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve excision of excess skin of the arms.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more towards the eyeglasses you purchased on May 5, 2022 
 You asked the Plan to pay more towards the eyeglasses. You say that the last time you purchased eyeglasses 
was in 2018, so this should be covered. The Plan denied your request. The Plan says it has already paid the 
$150 allowance towards these eyeglasses, so you have exhausted your vision benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eyewear up to $150 every two years.  The Plan has already paid $150 towards the 
eyeglasses you purchased on May 5, 2022.  Any amount over this $150 allowance is your responsibility. 
Therefore, we decided that the Plan does not have to pay more towards the eyeglasses you purchased on May 5, 
2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from January 29, 2021, to October 
14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you provided medical records to support 
payment. The Plan denied your request. The Plan says unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. 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 medical services provided from January 29, 2021, to October 14, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on January 19, 
2022. 
 
You asked the Plan to pay for procedure code 0037U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. 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 pay for the laboratory 
services (0037U) provided on January 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had a fall and is currently unable to 
walk. Rehabilitation is needed to help the enrollee get stronger. The Plan denied your request. The Plan says 
based on Medicare guidelines and the information we have about the enrollee's condition they do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee was admitted for falls after recent back surgery. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non emergent transportation (A0428) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve non emergent transportation. You say that you are bed bound and you need 
non-emergent transportation to dialysis services and treatment. The Plan denied your request. The Plan says 
The requested out-of-network provider is not contracted in the member's network. The Plan has confirmed that 
the services may be obtained in-network. 
 
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 
non emergent transportation (A0428) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from June 26, 2020, 
through July 2, 2020, billed with 8 units of room/board days. 
 
You asked the Plan to pay for the inpatient care as billed. You say that this was an adjustment bill to add two 
additional days to the inpatient claim. The Plan denied your request. The Plan says the number of units of 
inpatient days exceeds the date range reported on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient claims must report both the date range 
during which services were rendered, as well as the number of days in each type of inpatient bed.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient care as billed have not been met. Specifically, the date range reported on this claim is 
6 days, and the number of days reported in the revenue code is 8. The claim must reflect the number of days within the actual date range being reported. Therefore, we decided that the Plan does not have to pay for the 
inpatient hospital care provided from June 26, 2020, through July 2, 2020, billed with 8 units of room/board 
days.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that [Enter appellant's argument from appeal letter, e.g. 
"...you need SNF care."] The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatry visit, and x-ray provided on May 
19, 2022. 
 
You asked the Plan to waive the copayment for a podiatry visit and x-ray. You say that you were told the 
copayment would only be $27.02 for the visit and the plan would cover the rest. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment per day, per provider, for Medicare-covered x-ray services and a $45 copayment for each Medicare-
covered visit 
 
 
  You have been asked to pay a total copayment of $72.02 for a podiatry visit and x-ray. The total includes 
$27.02 for an x-ray, which is less than the standard $35 copayment, and a $45 copayment for a podiatry visit. 
An x-ray falls within the Outpatient diagnostic Tests and Therapeutic Services and Supplies benefit category. A 
podiatry visit falls within the Podiatry Services benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a podiatry visit, and x-ray provided on May 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the warranty you purchased with the eyeglasses you received 
on July 11, 2022. 
 
You asked the Plan to pay for the warranty. You say that you do not know why this bill wasn't paid in full. The 
Plan denied your request. The Plan says warranties are not covered under your vision benefit.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers only exams, frames and lenses.  Warranties are not listed as covered under your 
routine vision benefit. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the warranty have not been met. Therefore, we decided that the Plan does not have to pay for the 
warranty you purchased with the eyeglasses you received on July 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron 8mg tablets. 
 
You asked the Plan to pre-approve the ondansetron tablets. You say that this is necessary to treat 
chemotherapy-induced nausea and vomiting. The Plan denied your request. The Plan says this is not being used 
for the Medicare Part B covered indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs.  
 
 
 Though this is being used for chemotherapy-related nausea, it is not being given solely at the time of 
chemotherapy administration. This is the only time the drug can be covered by Medicare Part B. Therefore, we 
decided that the Plan does not have to pre-approve ondansetron 8mg tablets.  
 
Benefits for the ondansetron tablets 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 physical therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve therapy visits. You say that it is medically necessary to receive therapy with 
the requested provider. The Plan denied your request. The Plan says physical therapy services can be provided 
in-network. 
 
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 
15 physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 20, 2021, billed with 
codes 81230, 81240, 81241, 81249, 81291, 81335, and 81406. 
 
You asked the Plan to pay for the genetic testing billed. You say that this is medically necessary testing that 
was ordered by the treating physician. The Plan denied your request. The Plan says this single panel was billed 
with multiple gene codes, which is not allowed per Medicare billing rules. 
 
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 
October 20, 2021, billed with codes 81230, 81240, 81241, 81249, 81291, 81335, and 81406.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gym membership you purchased on January 18, 2022. 
 
You asked the Plan to pay for the gym membership. You say that you sent in a copy of the contract you signed, 
so you should be reimbursed. The Plan denied your request. The Plan says you did not provide a valid proof of 
payment with your reimbursement request. The Plan did pay for the four months where valid proof of payment 
was provided. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan does reimburse up to 
$175 per year for gym memberships under the wellness benefits.  However, when you submit a request for 
reimbursement, you need to include proof of payment.  In this case, you only provided proof of payment for the 
first 4 months of your gym membership.  We understand that you have signed up for a year membership and 
are paying monthly.  However, without proof that you have actually paid for additional months (via a receipt, 
credit card statement, etc.), the Plan cannot be required to reimburse you until/unless you supply that 
documentation. 
 
The Plans rules for coverage of gym benefits have not been met because [insert why the plan is not covering 
the gym benefit]. Therefore, we decided that the Plan does not have to pay for the gym membership you 
purchased on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
provided in good faith. The Plan denied your request. The Plan says unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. 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 medical services provided on April 15, 2022, by an out-of-
network (OON) provider.