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

 
We decided that the Plan does not have to pre-approve Fasenra for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Fasenra for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing provided on October 12, 2021. 
 
You asked the Plan to pay for the drug testing. You say that this was medically necessary drug testing. The 
Plan denied your request. The Plan says that the clinician did not support that this number of drug classes were 
medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the drug testing by a contract provider. The file does not show that the plan 
provided notice that the drug testing would not be covered. Under Medicare rules, this means the drug testing is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the definitive drug testing 
provided on October 12, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bariatric surgery provided to the enrollee on September 7, 
2021. 
 
You asked the Plan to pay for the surgery. You say that this was medically necessary. The Plan denied your 
request. The Plan says only Roux-en-Y gastric bypass (RYGBP), open and laparoscopic, is covered for 
Medicare beneficiaries. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the records do not document any prior medical attempts at weight loss. Although prior efforts may have 
been attempted, there is no provided documentation of such efforts provided for review at this time. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pay for bariatric surgery provided to the enrollee on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulator (PNS). 
 
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. Medicare rules say that PNS is covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has polyneuropathy with 
chronic non-radicular low back pain. She has had physical therapy, chiropractic therapy, diagnostic medial 
branch blocks, and radiofrequency ablation. Magnetic resonance imaging shows multilevel degenerative 
disease as well as facet arthropathy. The Sprint PNS is considered experimental in nature at this point in time 
and is therefore not reasonable 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 a Sprint peripheral nerve stimulator (PNS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the insertion of radiation therapy devices 
in vagina for radiation therapy (57156) provided from October 25, 2021, to November 8, 2021. 
 
You asked the Plan to reduce the copayment for the insertion of radiation therapy devices in vagina for 
radiation therapy. You say that the Evidence of Coverage (EOC) refers to radiation (radium and isotope) 
therapy  it clearly says the copayment is $20. You also say that one of the examples the EOC gives is of 
colorectal radiation, where the isotope needs to be inserted into a body cavity, and this is similar to the system 
used in your treatment, but in a different body cavity. The Plan denied your request. The Plan says you were 
charged the correct cost sharing amount. 
 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 $75 
copayment for same day outpatient surgery in an outpatient hospital facility.  
 
You have been asked to pay a $75 copayment for each visit for the insertion of radiation therapy devices in 
vagina for radiation therapy. The insertion of radiation therapy devices in vagina for radiation therapy falls 
within the outpatient hospital 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 reduce the copayment for 
the insertion of radiation therapy devices in vagina for radiation therapy (57156) provided from October 25, 
2021, to November 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance charges for the specialist 
office visit, Part B drug injections, and knee orthotic provided on September 27, 2021 to October 29, 2021. 
 
You asked the Plan to waive the copayment and coinsurance charges for the specialist office visit, Part B drug 
injections, and knee orthotic. You say that you did not appreciate getting an accumulated bill. The Plan denied 
your request. The Plan says the copayment and coinsurance charges are 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 $40 
copayment for per specialist visit, 20% coinsurance for Part B drugs, and 20% coinsurance for Medicare-
covered durable medical equipment. 
 
You have been asked to pay a total of $297.55. The specialist office visit is a $40 copayment, the knee orthotic 
is $21.48, which is 20% of the Plans allowed amount ($107.41). The Part B drug injection provided on 
September 27, 2021 (code J3301) is $1.03, which is 20% of the Plans allowed amount ($5.16). The eight 
subsequent Part B drug injections (code J7324) are $29.38 each, which is 20% of the Plans allowed amount 
for each ($146.91).  
 
A specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit 
category. Part B drug injections fall within the Medicare Part B Prescription drugs benefit category. A knee 
orthotic falls within the Durable Medical Equipment (DME) and Related Supplies 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 and coinsurance charges for the specialist office visit, Part B drug 
injections, and knee orthotic provided on September 27, 2021 to October 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83970) provided October 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of ESRD are included in the ESRD PPS as Part B services and are not paid separately as of 
January 1, 2011. 
 
We looked at the file and Medicare rules. Payment for this service is included in payment for the ESRD 
service. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (83970) provided October 
13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advanced care planning (99497-25) provided on November 
24, 2021. 
 
You asked the Plan to pay for advanced care planning. You say that this is supported in the records. The Plan 
denied your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that both the medically necessary evaluation and 
management (E/M) service billed with modifier -25 and the primary procedure must be appropriately and 
sufficiently documented by the physician or qualified nonphysician practitioner in the patients medical record 
to support the claim for these services. The rules also say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of advanced care planning (99497-25) 
provided on November 24, 2021. have been met. No documentation of the primary procedure was submitted to 
verify that modifier -25 was used correctly to bill the services at issuew. Therefore, we decided that the Plan 
does not have to pay for advanced care planning (99497-25) provided on November 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services rendered on October 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 11406. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon 
services rendered on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Pulmonary ventilation and perfusion 
imaging (78582) provided on December 27, 2021. 
 
You asked the Plan to waive the copayment for the pulmonary ventilation and perfusion imaging. You say that 
the services should be covered as you disagree with the charges. The Plan denied your request. The Plan says 
the copayment applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for Outpatient hospital services, specifically advanced imaging services. 
 
 You have been asked to pay a $275 copayment for the pulmonary ventilation and perfusion imaging. 
Pulmonary ventilation and perfusion imaging falls within the Outpatient hospital 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 Pulmonary ventilation and perfusion imaging (78582) 
provided on December 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extracorporeal photopheresis provided to the enrollee on 
September 1, 2021. 
 You asked the Plan to pre-approve the services. You say that the continuity of care for apheresis is in the best 
interest of the patient, and supported by the letter of medical necessity from the physician. The Plan denied 
your request. The Plan says there was no documentation of cutaneous T-cell lymphoma or lung allograft 
transplantation. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee has bronchiolotis obliterans in the setting of Castleman's disease. 
This diagnosis is not an enumerated indication for coverage. 
 
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 extracorporeal photopheresis provided to the enrollee on September 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a phenylephrine injection (J1097) 
provided on December 9, 2021. 
 
You asked the Plan to waive the coinsurance for the phenylephrine injection. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance 
applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs and the administration of them. 
 
 You have been asked to pay a 20% coinsurance for the phenylephrine injection (allowed is $411.28 x 20% = 
$82.26). Phenylephrine injections fall 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 a phenylephrine injection (J1097) provided on December 9, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle-foot orthosis rendered on August 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order or proof of delivery. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. The rules say that all 
DMEPOS suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid physician order or proof of delivery for the DME. 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 pay for the ankle-foot orthosis rendered on August 6, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services rendered by the out-of-network (OON) 
provider on November 19, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 had network providers available 
who could have provided the services at issue in this appeal. 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 the medical services rendered by the out-of-network (OON) provider on 
November 19, 2021.
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's condition could be taken care of in sub-acute rehabilitation. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical epidural steroid injection. 
 
You asked the Plan to pre-approve a cervical epidural steroid injection. The Plan denied your request. The Plan 
says a cervical epidural steroid injection is not medically necessary and does not meet the Medicare LCD 
criteria. 
 
The Plan follows Medicare rules.  
 
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 cervical epidural steroid injection. 
Our reviewer says that a cervical epidural steroid injection is not medically reasonable or necessary. Our 
physician reviewer found the Medicare LCD criteria requires 50% pain reduction for 3 months. This has not 
been achieved and therefore, the request is deemed 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 a cervical epidural steroid injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a cervical epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99212) provided on 
November 16, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment per office visit with your specialist provider.  
 
You have been asked to pay a $50 copayment for the specialist office visit provided. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the office visit (99212) provided on November 16, 2021.