Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refractive exam provided on October 15, 2022. 
 
You asked the Plan to pay for the refractive exam. You say that you had not received eyeglasses for the year 
and the Plan should cover the cost. The Plan denied your request. The Plan says the benefit has been exhausted 
for the annual eye exam. 
 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 one routine eye exam per year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for a refraction on January 17, 2022, 
which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the 
refractive exam have not been met. Therefore, we decided that the Plan does not have to pay for the refractive 
exam provided on October 15, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a DecisionDx-Melanoma test (81529) provided on June 29, 2022.

You asked the Plan to pay for a DecisionDX-Melanoma test. You say that you disagree with the denial and this test should be a covered benefit for the enrollee. The Plan denied your request. The Plan says the requested test was not reasonable or necessary, in accordance with Medicare's guidelines. DecisionDX is not Food and Drug Administration (FDA) approved.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. The requested test does not meet criteria as the records show the enrollee has pT1a melanoma, with no documented concern about adequacy of microstaging, which does not meet the Medicare requirement for this test. There is no evidence that the use of DecisionDx changes the outcome of enrollees with melanoma. Based on this information, we decided that Medicare rules for coverage of a test have not been met. Therefore, we decided that the Plan does not have to pay for a DecisionDx-Melanoma test (81529) provided on June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 at home test kits provided from October 24, 
2022, to December 12, 2022. 
 
You asked the Plan to pay for COVID-19 at home test kits. You say that if Medicare reimburses, you should be 
reimbursed for it. The Plan denied your request. The Plan says the Original Medicare red, white, and blue card 
would need to be presented at the time of purchase. The Plan also says that you cannot submit a claim per the 
CMS guidance. 
 
The Plan must follow Medicare rules Medicare rules say that enrollees cannot submit a claim for these tests to 
Medicare or their MA plan (unless covered by a supplemental benefit) for reimbursement under this initiative. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of COVID-19 at home test kits have not been met. Therefore, we decided that the Plan does not have 
to pay for COVID-19 at home test kits provided from October 24, 2022, to December 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not need 
daily skilled therapy or nursing care. 
 
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 services. Our physician reviewer 
found that the most recent therapy documentation indicates you are at or near your prior level of function. You 
are without any acute exacerbations of chronic medical problems. You do not have any complex daily wound 
care, parental medications or require care for a new or malfunctioning feeding tube. You do not require skilled 
nursing and/or skilled therapy services on a daily basis. Therefore, an admission to a SNF for inpatient skilled 
services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
September 19, 2022, to September 26, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 $350 
copayment per day for days 1-5 and a $0 copayment per day for days 6 and beyond for inpatient hospital care.  
 
You have been asked to pay a $350 copayment per day for days 1-5 and a $0 copayment per day for days 6 and 
beyond for inpatient hospital care. The total amount you are being asked to pay $1,750 ($350 x 5 days = 
$1,750). This item/service falls within the inpatient hospital 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 inpatient hospital care provided on September 19, 2022, to September 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J8097). 
 
You asked the Plan to pre-approve Prolia. You say that the requested treatment would be appropriate for 
someone who is on continuous androgen deprivation therapy (ADT). You also say that this drug is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested drug is not medically 
necessary. 
 
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 Prolia. Our reviewer says that the 
requested use of Prolia is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
reviewer found that Medicare approved cancer drug compendia do not contain a supportive citation for the use 
of the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested use of 
Prolia 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J8097).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the breathing capacity test (94010) provided on December 3, 2021. 
 
You asked the Plan to pay for the breathing capacity test. You say that the Plan is liable for payment due to the 
medical group denying services due to the claim being out of area. The Plan denied your request. The Plan says 
that the enrollee's Independent Practice Association (IPA)/Physician Hospital Organization (PHO) is 
responsible for this service. 
 
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 records do not support that the enrollee's IPA/PHO is responsible for this 
service. This means that the Plan has not provided a valid reason for denying payment of the breathing capacity 
test. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not 
been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the 
breathing capacity test (94010) provided on December 3, 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 Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs proton beam therapy 
for his re-irradiation case. The Plan denied your request. The Plan says the documentation does not support the 
medical necessity of the services. 
 
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 metastatic castrate resistant prostate cancer and increasing posterior hip 
pain. Proton beam therapy is not medically reasonable and necessary in this case. Pain from metastatic cancer 
in the bone can be effectively palliated with a short course of external beam, photon-based radiation. There is 
no scientific evidence that retreatment of a prior radiated lymph node region with proton beam is beneficial. 
 
 
 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 proton beam radiation therapy (PBRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary 
The Plan denied your request. The Plan says a pneumatic compression device (PCD) that provides intermittent 
limb compression for the purpose of prevention of 
venous thromboembolism (E0676) is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intra-oral and bitewing x-rays (D0274, D0220) provided on 
October 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 14, 2022. 
Therefore, we decided that the Plan does not have to pay for intra-oral and bitewing x-rays (D0274, D0220) 
provided on October 20, 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 is at a higher risk for further medical 
complication with a transition to a subacute facility. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and the enrollee's needs can be met at a lower level of care. 
 
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 that the enrollee does not require intensive rehabilitation as their needs can be met at 
an outpatient 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace (L0650), provided on October 4, 2022. 
 
You asked the Plan to pay for the back brace. You say that the item was medically necessary. The Plan denied 
your request. The Plan says there is no mention of the braces in the referring physicians records. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. There is no discussion of braces or the need of in the medical records. 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 back brace (L0650), provided on October 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B Prescription Drugs 
provided on February 1, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B Prescription Drugs. You say that you 
disagree with the coinsurance. 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 20% 
coinsurance for Medicare Part B Prescription Drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B Prescription Drugs. The total allowed 
amount for the prescription drugs is $814.80. You are being asked to pay $162.96 ($814.80 x 20% = $162.96). 
This item/service falls within the 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 coinsurance for Medicare Part B Prescription Drugs provided on February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pharmacogenomics testing. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says non-
genetic factors have not been considered. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is only covered under 
certain medical indications.  
 We looked at the file and Medicare rules. The limited medical records show that the testing was ordered to 
make decisions about the enrollees medications. Medications should be provided based on the presence of a 
diagnosis and should be adjusted based on a response to the medication. It is not necessary to do genetic testing 
to provide or adjust medications. Furthermore, genetic markers may or may not correlate with actual clinical 
findings. 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 pharmacogenomics testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron 4mg tablets. 
 
You asked the Plan to pre-approve the ondansetron tablets. You say that the enrollee has biliary disease which 
causes frequent nausea and vomiting. This drug has been beneficial and should be covered. The Plan denied 
your request. The Plan says this drug is not prescribed for a Medicare Part B covered indication. Part D 
coverage must be requested. 
 
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 pre-approve ondansetron 4mg 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. You say that the requested drug is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the enrollee has not tried and failed one of the 
preferred drugs. 
 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 Hyalgan. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed one of the plan's preferred drugs. The reviewer found that the 
documentation does not indicate that the enrollee has a contraindication to or would have an adverse effect 
from one of the plan's preferred drugs. Therefore, the reviewer found that the step therapy criteria have not 
been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan (J7321).
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 need to be in a SNF. The Plan denied your 
request. The Plan says a SNF admission is not medically necessary, and your needs can be met at an alternate 
level of care. 
 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 or skilled therapy on an inpatient basis in a 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that the enrollee qualifies for the 
homebound physical therapy care. The Plan denied your request. The Plan says the provider is out-of-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 physical therapy visits. We found no exception that would require the Plan to pre-
approve the physical therapy visits. Therefore, we decided that the Plan does not have to pre-approve the 
physical therapy visits to be provided by an out-of-network (OON) provider.