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

 
We decided that the Plan does not have to pay for the Rituximab (J9312) provided on August 6, 2021 by an 
out-of-network (OON) provider. 
 You asked the Plan to pay for the Rituximab. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says there was no prior authorization on file and the servicing provider is 
not contracted with the Plan. The Plan also says that all care with non-contracted providers requires 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the Rituximab (J9312) provided on August 6, 
2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a portable oxygen concentrator provided 
from October 9, 2021, to November 9, 2021. 
 
You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that the equipment was fully 
covered by the Plan for previous months. The Plan denied your request. The Plan says the correct coinsurance 
was applied. 
 
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 equipment and supplies, including oxygen equipment. 
 
 
 Item Allowed Amount 20% Coinsurance 
Delivery Port (E1390)  October 9, 2021 $103.26 $20.65 
Oxygen Concentrator (E1392)  October 9, 2021 $82.50 $16.50 
Delivery Port (E1390)  November 9, 2021 $103.26 $20.65 
Oxygen Concentrator (E1392)  November 9, 2021 $82.50 $16.50 
Total:  $74.30 
 
You have been asked to pay $74.30, which is 20% of the allowed amount for the oxygen concentrator. Please 
note that previous charges were covered by the Plan under their COVID-19 waiver. This waiver ended on 
September 30, 2021. The oxygen concentrator 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 coinsurance for a portable oxygen 
concentrator provided from October 9, 2021, to November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on September 22, 
2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you would not have gone to this 
provided if you knew they were out of network. The Plan denied your request. The Plan says you have been 
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 $45 
copayment for in-network exams to diagnose and treat diseases or conditions of the eye. 
 
You have been asked to pay a $45 copayment for the eye exam. The eye exam falls within the Vision 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 an eye exam provided on 
September 22, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for iodine dye provided on October 9, 2020. 
 
You asked the Plan to waive the coinsurance for iodine dye. You say that you expected the dye would have 
been covered according to your plan. The Plan denied your request. The Plan says that you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.  
 
The Plan says you must pay 20% coinsurance for iodine dye. However, according to Medicares Outpatient 
Prospective Payment System, iodine dye (code A9584) is not a separately payable item. This means that it is 
not subject to separate cost sharing. Therefore, we decided that the Plan has to waive the coinsurance for iodine 
dye provided on October 9, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01992 billed for date of service September 
30, 2021. 
 You asked the Plan to pay for procedure code 01992. You say that these procedures were performed at 
different times by different anesthesiologists, so this code should be paid. The Plan denied your request. The 
Plan says payment for this code is bundled into payment for 64483. The Plan says that there are no 
circumstances in which this code pair can be paid for the same beneficiary on the same day. 
 
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, we have confirmed that code 01992 
is a column II code to column I code 64483. Based on the claim submitted, Medicare billing criteria have not 
been met. The National Correct Coding Initiative edits says that there are no modifiers allowed with this code 
pair. Therefore, we decided that the Plan does not have to pay for procedure code 01992 billed for date of 
service September 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ziextenzo. 
 
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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chemotherapy-related 
neutropenia/febrile neutropenia. She has not tried and failed the Plan's required drugs, Neulasta, Fulphila, or 
Udenyca. The records do not show that the required drugs would be contraindicated or less effective; therefore, 
Ziextenzo is 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 Ziextenzo.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility services provided 
October 12, 2021 to November 12, 2021. 
 
You asked the Plan to waive the copayment for the skilled nursing facility services. You say that the 
copayment should only be $200. The Plan denied your request. The Plan says the correct copayment was 
applied. 
 
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 per-day copayment for days 1 through 20 of a skilled nursing benefit period.  
 
The enrollee has been asked to pay a $400 copayment for the skilled nursing facility services ($20 per-day, for 
20 days). 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 copayment for skilled nursing facility services 
provided October 12, 2021 to November 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox and the administration (J0585, 64642, 64643). 
 
You asked the Plan to pre-approve Botox and the administration. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the member has not met the step therapy requirement. 
 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 Botox and the administration. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
does not indicate the enrollee has tried and failed the Plan's step therapy requirements or that the Plan's required 
drugs would likely be less effective and/or have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox and the administration have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Botox and the administration (J0585, 64642, 64643).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a craniectomy with stereotactic implantation of 
neurostimulator electrode array in subcortical site (61867) to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve a craniectomy with stereotactic implantation of neurostimulator electrode 
array in subcortical site. You say that you suffer from Parkinson's disease and are being scheduled for surgery 
with your current doctor that you have had for over a year in preparation for deep brain stimulation surgery. 
You also say that you have already underdone testing in preparation for the surgery, also covered by the Plan, 
and you are in constant communication with the office and have developed a relationship with the doctor and 
the staff. The Plan denied your request. The Plan says there are in-network providers available. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 craniectomy with stereotactic implantation of neurostimulator electrode 
array in subcortical site. Our reviewer says that this does not meet criteria. Our physician reviewer found that 
based on the medical records provided there is no documentation that the office visit for deep brain stimulation 
(61867) with this provider is medically reasonable and necessary as opposed to using an in-network provider 
for the services. The records do not document that the in-network provider would not be able to provide 
necessary care 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 a craniectomy with stereotactic implantation of neurostimulator electrode array 
in subcortical site have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve a craniectomy with stereotactic implantation of 
neurostimulator electrode array in subcortical site. Therefore, we decided that the Plan does not have to pre-
approve a craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site 
(61867) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
September 16, 2021 to, September 23, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered in full due to your diagnosis of COVID-19. The Plan denied your request. The Plan says the cost-
sharing 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 $350 
copayment per day for days 1-5 of Inpatient hospital care.  
 
 
  You have been asked to pay a $1,750 copayment for 5 days of inpatient hospital care ($350 x 5 = $1,750). 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 an inpatient hospital stay provided from September 16, 2021 
to, September 23, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (CPT code(s): 90868, 
90869, 90867). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been 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 the services. Our physician reviewer 
found this patient does not meet the clinical criteria for the use of TMS therapy utilizing LCD (L34522) as this 
patient is currently responding to electroconvulsive treatment (ECT). The patient is responding to 
psychotherapy utilizing cognitive behavioral therapy and dialectic behavioral therapy although there is no 
documentation of improvement based on standardized testing. Utilizing the information from this enrollee that 
indicates this patient does have an indication for the requested TMS, this patient does not meet the LCD 
requirement for TMS in the treatment of Schizoaffective Disorder Depressed Type or Major Depressive 
Disorder. 
 
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 transcranial magnetic stimulation (CPT code(s): 90868, 90869, 90867).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for durvalumab injections provided on 
September 8, 2021, and October 6, 2021. 
 
You asked the Plan to waive the copayment for the durvalumab injections. You say that the services should be 
covered as you have not received any of these services. 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 5% 
coinsurance for Medicare Part B Prescription Drugs.  
 
 
 You have been asked to pay a 5% coinsurance for two durvalumab injections (total allowed is $15,340 x 5% = 
$767.30). Durvalumab 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 copayment for durvalumab injections provided on September 8, 2021, and 
October 6, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member's nursing, medical management and rehabilitation needs do 
not require an interdisciplinary team approach for the delivery of rehabilitation care at this time. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for pneumonia and 
urinary tract infection. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 5 mg tablet. 
 
You asked the Plan to pre-approve Eliquis. You say that the requested drug is medically reasonable and 
necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
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 Eliquis 5 mg tablet.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee has severe osteoporosis. The Plan denied 
your request. The Plan says the enrollee has not tried and failed Prolia or Reclast. 
 
 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 Evenity. Our physician reviewer found 
that the enrollee has post-menopausal osteoporosis. The Plan requires a trial of Prolia or Reclast before they 
will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is 
no documentation provided indicating that the plans required drugs would likely be less effective 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foot orthotic (L1960). 
 
You asked the Plan to pre-approve a foot orthotic (L1960). You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ankle-foot orthoses (AFO) are covered for 
ambulatory beneficiaries with weakness or deformity of the foot and ankle, who meet the criteria 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 a foot orthotic. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the documentation does not reveal 
extenuating factors on objective physician progress notes that require a custom ankle foot orthosis or why the 
patient's needs cannot be met with a prefabricated ankle foot orthosis. 
 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 foot orthotic have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a foot orthotic (L1960).