Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled care. 
 
You asked the Plan to pre-approve home health. You say that the enrollee is homebound and is in need of 
skilled nursing. The Plan denied your request. The Plan says the denial of authorization for home health care is 
correct. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer found 
the enrollee does not have documented skilled nursing or skilled physical therapy needs, and is already 
functioning at a level commensurate with a lower level of care such as home exercise program, outpatient care, 
or layperson supervision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health skilled care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on January 10, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) provided on July 19, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that there is no way you could have known the 
optometrist you saw was OON. You also say that everything is supposed to be covered. The Plan denied your 
request. The Plan says you pay a $55.00 copayment for an eye exam from an OON provider.  
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. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you were seen for a medical 
exam. You are responsible for a $55 copayment per Medicare-covered visit by an OON provider. Based on this 
information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we 
decided that the Plan does not have to pay for the eye exam (92014) provided on July 19, 2022 by an out-of-
network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdualag. 
 
You asked the Plan to pre-approve Opdualag. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Opdualag. Our reviewer says that this 
drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
Keytruda or Opdivo (as monotherapy) or Opdivo in combination with Yervoy before they will approve the 
requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation 
provided indicating that the plans required drug(s) would likely be less effective and/or likely have adverse 
effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdualag have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Opdualag.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services with refraction provided on 
February 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services with refraction. You say that the services were 
medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
ophthalmological services with refraction. We found no exception that would require the Plan to pay for the 
ophthalmological services with refraction. The records provided for review do not show that the services at 
issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the 
ophthalmological services with refraction provided on February 22, 2022, by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital services on August 17, 
2021 to August 22, 2021. 
 
You asked the Plan to waive the coinsurance for inpatient hospital services. You say that the services provided 
were medically necessary. The Plan denied your request. The Plan says the cost share applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 35% 
coinsurance for inpatient hospital services. The total allowed amount of the inpatient hospital care is $9,885, 
resulting in a coinsurance amount of $3,459.25. 
 
You have been asked to pay a 35% coinsurance for inpatient hospital services. Inpatient hospital services fall 
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 coinsurance for 
inpatient hospital services on August 17, 2021 to August 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chemical adhesive endovenous ablation therapy of 
incompetent vein (36482) 
 
You asked the Plan to pre-approve chemical adhesive endovenous ablation therapy. You say that the requested 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity 
rules for the requested services have not been met. 
 
The Plan must follow Medicare rules. The rules say that invasive procedures for the treatment of varicose veins 
are considered medically reasonable and necessary when the criteria listed in the Medicare rules section 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 chemical adhesive endovenous ablation 
therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that coverage criteria are not met because it is not possible to attribute 
the enrollee's symptoms to varicose veins nor is it possible to support the reasonableness of great saphenous 
vein treatment in the presence of significant peripheral arterial disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chemical adhesive endovenous ablation therapy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve chemical adhesive endovenous ablation therapy of 
incompetent vein (36482)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 16, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee could not choose 
another provider because no other providers were allowed in the facility during the coronavirus pandemic. The 
Plan denied your request. The Plan says no prior authorization was obtained. 
 
 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
subsequent nursing facility care. We found no exception that would require the Plan to pay for the subsequent 
nursing facility care. The records provided for review do not show that subsequent nursing facility care was 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility 
care provided on February 16, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cerebral perfusion analysis using computed tomography 
(CT) (0042T) provided on December 25, 2021. 
 You asked the Plan to pay for the cerebral perfusion analysis using CT. You say that you would like this claim 
to be reconsidered for processing. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules state that computed tomography cerebral perfusion analysis is 
only covered under certain circumstances. 
 
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 cerebral perfusion analysis using CT. 
Our reviewer says that the cerebral perfusion analysis using CT was not reasonable and necessary. Our 
physician reviewer found a cerebral perfusion analysis using computed tomography (CT) (0042T) is utilized to 
measure brain penumbra in the face of documented vessel occlusion which may be amenable to thrombectomy. 
Our reviewer also found that no such occlusion was documented on the Computed Tomography Angiography 
(CTA) to qualify for such reimbursement 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 cerebral perfusion analysis using CT have not been met. Therefore, we 
decided that the Plan does not have to pay for the cerebral perfusion analysis using computed tomography (CT) 
(0042T) provided on December 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomographic angiography (CTA), abdomen 
and pelvis, with contrast material (74174) provided on September 16, 2021. 
 
You asked the Plan to pay for the CTA. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the computed tomographic angiography (CTA), abdomen and 
pelvis, with contrast material (74174) provided on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 8, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
codes cannot be verified. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that a urinary tract infection panel was ordered and billed with multiple codes. If a single 
procedure is performed, only one code with one unit of service may be reported for the procedure. The medical 
records provided do not show that the service billed with the -59 modifier is a distinct procedural service. 
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 lab services provided on April 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $250 copayment for outpatient surgery performed on 
February 15, 2022. 
 
You asked the Plan to waive the $250 copayment for outpatient surgery performed on February 15, 2022. You 
say that you have had this procedure in the past and it has not been considered a surgical procedure. The Plan 
denied your request. The Plan says you must pay a $250 copayment for outpatient surgery. 
 
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 $250 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
 You have been asked to pay a $250 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the $250 copayment for outpatient 
surgery performed on February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the enrollee is in danger of dying without 
this machine. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set 
in AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. This patient has very severe COPD with a 
recent exacerbation, and chronic CO2 retention. The patient has been prescribed BiPAP at home but does not 
use it. BiPAP with the AVAPS mode during sleep could benefit the patient, but the patient is apparently unable 
to use BiPAP, and therefore would likely not use a ventilator since the interface is identical. Medicare does not cover a ventilator when used as BiPAP. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for a portable ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that this is medically necessary. The Plan denied your 
request. The Plan says this use is not supported. 
 
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 Opdivo. Our reviewer says that the 
requested use of Opdivo is not supported. Our physician reviewer found the use of Opdivo as monotherapy for 
non-small cell lung cancer without additional information on the tumor is not Food and Drug Administration-
approved and is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve moderate (conscious) sedation. 
 
You asked the Plan to pre-approve moderate (conscious) sedation. You say that sedation with facet injections is 
medically necessary to control the patient's pain level. You say that the provider monitors the patient the entire 
time they are sedated. The Plan denied your request. The Plan says general anesthesia is considered not 
reasonable and necessary for facet joint interventions. Neither conscious sedation nor monitored anesthesia 
care is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely 
reimbursable. 
 
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 moderate (conscious) sedation.  Our reviewer says that moderate (conscious) sedation is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that there is no documentation provided for unique circumstances 
indicating a medical necessity for sedation for this procedure. General anesthesia is considered not reasonable 
and necessary for facet joint interventions. Neither conscious sedation nor monitored anesthesia care is 
routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely 
reimbursable. Individual consideration may be given on redetermination (appeal) for payment in rare, unique 
circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical 
record. The review has determined that the requested moderate (conscious) sedation at issue in this case 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 moderate (conscious) sedation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve moderate (conscious) sedation (code 99152).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277) (a 
three-month low air loss mattress rental). 
 
You asked the Plan to pre-approve a low air loss mattress rental. You say that the requested mattress is 
medically necessary. The Plan denied your request. The Plan says the requested mattress does not meet criteria. 
 
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 a low air loss mattress rental. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not reveal that you have multiple stage 2 pressure 
ulcers on the trunk or pelvis. The documentation does not reveal large or multiple stage 3 or 4 pressure ulcer(s) 
on the trunk or pelvis or a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the 
past 60 days. 
 
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 low air loss mattress rental have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277) (a three-month low air 
loss mattress rental).