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

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 
You asked the Plan to pre-approve Entyvio. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Stelara. 
 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 Entyvio. 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 the preferred drug, Stelara. The reviewer found that the there is no 
indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the 
enrollee. 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 there is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 
visits weekly to regain or maintain the enrollee's functional status. The enrollee can receive further services 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first hour of critical care (99291) billed for date of 
service June 30, 2021. 
 
You asked the Plan to pay for the first hour of critical care. You say that you have provided records to support 
the service billed. The Plan denied your request. The Plan says rules for payment have not been met because 
the medical records do not support the service at issue. 
 
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 available medical record 
does not clearly specify the duration of the service at issue. Based on this information, we decided that 
Medicare rules for coverage of the first hour of critical care have not been met. Therefore, we decided that the 
Plan does not have to pay for the first hour of critical care (99291) billed for date of service June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 22. 
 
You asked the Plan to pre-approve the dental service. You say that tooth # 22 has extensive caries and fracture 
present. You say that there is adequate tooth structure for a favorable prognosis. You also say that the service is 
necessary. The Plan denied your request. The Plan says the crown is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
service when the services are medically necessary and reasonable.  
 
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 dental service. Our reviewer says 
that the crown for tooth # 22 is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that tooth # 22 has significant breakdown that would warrant a crown. 
Therefore, the reviewer found that the requested crown for tooth # 22 is not medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740) for tooth # 22.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the renal dialysis services provided to the 
enrollee from January 3, 2022, to April 29, 2022. 
 
You asked the Plan to waive the coinsurance. You say that the enrollee shouldn't have to pay for these services. 
The Plan denied your request. The Plan says the cost share applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for renal dialysis services.  
 
Review of the file shows that enrollee received renal dialysis services from January 3, 2022, to April 9, 2022. 
The enrollee has been asked to pay a 20% coinsurance for the services. The services falls within the renal 
dialysis services benefit category. This means that the enrollee has been asked to pay the correct amount based 
on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the renal 
dialysis services provided to the enrollee from January 3, 2022, to April 29, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 26, 2022, to April 
29, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this hospital stay met medical 
necessity criteria for an inpatient stay. The Plan denied your request. The Plan says that the inpatient stay 
cannot be approved. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the records show that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation 
care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from April 26, 2022, to April 29, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye exam (92004) provided on May 3, 2022. 
 
You asked the Plan to pay for an eye exam. You say that you called the plan's customer service and asked for a 
referral. The Plan denied your request. The Plan says this service is not covered out of network. 
 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 these services when it is provided by an in-network provider. 
 
We looked at the file and the Plan's rules. The records show that the service at issue was provided by an out-of-
network provider. This service is not covered by the Plan when provided by an out-of-network provider. Based 
on this information, we decided that the Plan's rules for coverage of an eye exam have not been met. Therefore, 
we decided that the Plan does not have to pay for a medical eye exam (92004) provided on May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the perfusion services provided on March 10, 2022. 
 
You asked the Plan to pay for the services provided. You say that the services were ordered by the surgeon. 
The Plan denied your request. The Plan says the services are included in the payment made to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary.  
 
We looked at the file and the rules. The facility must furnish all necessary covered services to the beneficiary 
either directly or under arrangements made with outside providers. This service was provided via arrangement 
of the facility. Payment for this service would have been included under the facility claim. Payment to you for 
this service is the responsibility of the facility.  Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the perfusion services provided on March 10, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tadalafil 5MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the Tadalafil tablet to be administered at home is not Medicare covered under the 
Part A or B benefit. 
 
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 Tadalafil 5MG tablet.   
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the member has spondylosis without 
myelopathy or radiculopathy. The Plan denied your request. The Plan says that your request is not medically 
necessary because the records show the enrollee does not have greater than or equal to 80% improvement with 
two previous MBB injections. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The enrollee did not 
achieve at least 80% pain relief on each set of MBBs. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on May 20, 2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you went in for a screening 
colonoscopy, and now you're getting charged for outpatient hospital service. The Plan denied your request. The 
Plan says the copayment that was applied was correct. A polyp removal changes the procedure from a 
screening to a diagnostic. 
 
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 $290 
copayment for a Medicare covered outpatient hospital facility visit.  
 
You have been asked to pay a $290 copayment for a colonoscopy. A colonoscopy falls within 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 a colonoscopy 
provided on May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) billed for date of service February 
16, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the claim did not include a unique test identifier. 
 
The Plan must follow Medicare rules. Medicare rules say that all MDT services must include an identifier as 
additional claim documentation. 
 
 
  We looked at the file and Medicare rules. In this case, the claim for the service at issue was not submitted with 
a unique test identifier. Based on this information, we decided that Medicare rules for coverage of genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0037U) 
billed for date of service February 16, 2022.
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 you are appealing this denial. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for IRF 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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee would benefit from occupational and physical therapy, but this does not require the intensity of therapy 
provided in acute inpatient rehabilitation. 
 
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 pay for the services (96372) provided on March 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 96372 is not supported in the medical record. Specifically, code 96372 is 
assigned an OPPS status indicator of Q1. This means that if this code is billed on the same claim as a code with a status indicator of S, T, or V, it is not separately payable. In this case, code 99284, which has a status 
indicator of V, was billed on the same claim. As such, code 96372 is not separately payable. 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 services (96372) provided on March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids (V5261) provided on March 22, 
2022. 
 
You asked the Plan to reimburse you for hearing aids. You say that you disagree with the denial and are 
requesting reconsideration of reimbursement of the hearing aids purchased online. The Plan denied your 
request. The Plan says you are required to contact the Plan's hearing vendor to access the routine hearing exam 
and supplemental hearing aid benefits. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids when provided by the hearing aid vendor for the Plan.  
 
We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the 
Plan. The Plan has a hearing vendor available who can provide the items/services at issue in this appeal. Based 
on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, 
we decided that the Plan does not have to reimburse you for hearing aids (V5261) provided on March 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided February 25, 2021 to March 6, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the diagnosis code billed is not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with a primary diagnosis code of A41.9 (Sepsis, 
unspecified organism). 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 inpatient care. Our 
reviewer says that the diagnosis code billed is not supported in the records. Our physician reviewer found 
sepsis was not clearly supported by indicators in the record as inflammatory markers can elevated in localized 
infections as well as sepsis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient care provided February 25, 2021 to March 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Privigen injections and intravenous 
infusions provided by an out-of-network provider on May 23, 2022, and May 24, 2022. 
 
You asked the Plan to waive the coinsurance for the Privigen injections and intravenous infusions. You say that 
the facility never disclosed they were out-of-network, and an estimate of charges should have been discussed. 
You say that they did get prior authorization before making the appointment so there is no reason finances were 
never discussed. The Plan denied your request. The Plan says the out-of-network coinsurance applied 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 45% 
coinsurance for chemotherapy drugs and all other drugs covered under Medicare Part B. Your contract with the 
Plan clearly says that you must pay 45% coinsurance for out-of-network physician specialist services.  
 
You have been asked to pay a total of $3,656.30 for the Privigen injections and intravenous infusions.  
 
Date of Service Service Allowed Amount Coinsurance Member Liability 
May 23, 2022 Privigen Injection $3,604.16 45% $1,621.87 
May 23, 2022 Intravenous Infusions $458.40 45% $206.28 
May 24, 2022 Privigen Injection $3,604.16 45% $1,621.87 
May 24, 2022 Intravenous Infusions $458.40 45% $206.28 
TOTAL:    $3,656.30 
 
The Privigen injections fall within the Medicare Part B Prescription Drugs benefit category. The intravenous 
infusions fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 the Privigen injections and intravenous infusions provided 
by an out-of-network provider on May 23, 2022, and May 24, 2022.