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

 
We decided that the Plan has to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you are appealing the SSBCI program 
denial. The Plan denied your request. The Plan says that you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan did not send us medical records. You say that you should 
be eligible for SSBCI benefits due to your health issues. Without medical records, we cannot determine 
whether or not you are eligible for the benefits. Therefore, the Plan has not shown that their decision to deny 
the benefit is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pre-
approve the SSBCI benefits.  
 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio (J1306). 
 
You asked the Plan to pre-approve Leqvio. The Plan denied your request. The Plan says this drug is not found 
to be reasonable and necessary based on review of compendia. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Leqvio. Our reviewer says that the 
documentation does not support that Leqvio (J1306) is medically reasonable and necessary for the enrollee. 
Our physician reviewer found the use of Leqvio (inclisiran) for treatment of mixed hyperlipidemia has only 
demonstrated benefit when used as an adjunct to diet and with maximally tolerated high intensity statin (for 
example: atorvastatin or rosuvastatin) in patients that have failed to achieve goal low-density lipoprotein 
cholesterol (LDL-C) reduction; or is determined to have statin-associated muscle symptoms (SAMs). Our 
reviewer also found that the documentation does not support that Leqvio (J1306) is safe and effective 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 Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio (J1306).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and a 
specialist office visit provided on August 12, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and a specialist office visit. 
You say that you disagree with the cost share. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B Prescription Drugs and a $45 copayment for a physician/practitioner services 
specialist.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B Prescription Drugs and a $45 copayment 
for a physician/practitioner services specialist. The total allowed amount for the prescription drugs is $5291.10. You are being asked to pay $1,058.22 ($5291.1 x 20% = $1,058.22). The total amount you are being asked to 
pay is $1,103.22 ($1,058.22 + $45 = $1,103.22). This item/service falls within the Medicare Part B Prescription 
Drugs and a physician/practitioner services specialist 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 
cost share for Medicare Part B prescription drugs and a specialist office visit provided on August 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical, multiple post collar (L0180) provided on 
October 7, 2022. 
 
You asked the Plan to pay for the cervical, multiple post collar. You say that you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says the documentation submitted did not include a valid 
physician order. The Plan also says the documentation submitted did not sufficiently support the billed supply 
code. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, none of the provided documentation shows an 
itemized list or the quantity of the delivered item(s). The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the cervical, multiple post collar (L0180) provided on October 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 14, 2021. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee was not enrolled hospice at the 
time of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 13, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel testing provided on December 
3, 2022. 
 
You asked the Plan to pay for the billed services. You say that the lab results show the work that has been 
performed. The Plan denied your request. The Plan says the testing is excluded from coverage. 
 
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 looked at the file and the rules. Panes with greater than 5 respiratory pathogens are considered not 
medically reasonable and necessary. There are no medical records, including an order/requisition form, 
indicating what testing was ordered and the reasonableness or the testing. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for the respiratory pathogen panel testing provided on December 3, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the IONM. We decided that the Plan does not have to pay for the NMJ 
testing.   
You asked the Plan to pay for the neuromuscular junction (NMJ) testing (95937), and continuous intraoperative 
neurophysiology monitoring (IONM) (G0453 x 5) provided on June 16, 2021. You say that the services were 
medically necessary for the enrollee. The Plan says that the services are considered experimental and 
investigational. 
 
We decided that the Plan has to pay for the IONM.  
 
The Plan follows Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or 
service, then that item or service will be covered when it is medically necessary. 
 
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 IONM. Our reviewer says that the IONM 
is medically necessary. Our physician reviewer found that it has become frequent or a standard of care for 
surgeons to elect to use IONM during such procedures to monitor cranial function, particularly given the 
clamping of the carotid. Therefore, the reviewer found that procedure code G0453 was reasonable and 
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 the IONM have been met. Therefore, we decided that the Plan has to pay for the 
IONM.  
 
We also decided that the Plan does not have to pay for the NMJ testing. 
 
The Plan follows 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 NMJ testing. Our reviewer says that the 
NMJ testing is not medically necessary. Our physician reviewer found there is not a reason to formally perform 
any form of NMJ testing during this procedure. The reviewer found that there was not any testing done during 
the course of the procedure that would meet the procedure code definition of 95937.  There was no formal 
evaluation of disorders of the NMJ. In as much this service cannot be said to have been supported and therefore 
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 the NMJ testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the NMJ testing. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room visit provided on March 20, 2022. 
 
You asked the Plan to pay for emergency room visit. You say that the claim needs to be reprocessed. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 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 emergency room visit provided on March 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on October 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that the test is a covered Medicare benefit. The Plan 
denied your request. The Plan says the claim did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. The claim does not show that the required unique identifier was 
reported. 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 the lab testing services provided on 
October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says that you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan did not send us medical records. You say that you should 
be eligible for SSBCI benefits due to your health issues. Without medical records, we cannot determine 
whether or not you are eligible for the benefits. Therefore, the Plan has not shown that their decision to deny 
the benefit is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pre-
approve the SSBCI benefits. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the lumbar surgery services provided on October 19, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says that a clinical trial number is missing. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Plan denied the services as a transcatheter aortic valve replacement is 
only covered in the context of a clinical study. However, the service at issue, billed under code 0275T, was a 
lumbar decompression procedure. Neither the medical records nor the claim indicates that a valve replacement 
was billed or provided. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the lumbar surgery services provided on October 19, 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 an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210), bone replacement graft for ridge preservation - per site (D7953), guided tissue 
regeneration - resorbable barrier, per site (D4266), periodontal scaling and root planing - one to three teeth per 
quadrant (D4342), localized delivery of antimicrobial agents via a controlled release vehicle into diseased 
crevicular tissue, per tooth (D4831), intravenous moderate (conscious) sedation/analgesia- first 15 minutes 
(D9239), intravenous moderate (conscious) sedation/analgesia  each subsequent 15 minute increment 
(D9243), surgical placement of implant body: endosteal implant (D6010), and bone graft at time of implant 
placement (D6104) provided on January 29, 2020, and September 9, 2020. 
 
You asked the Plan to pay for codes D7210, D7953, D4266, D4342, D4831, D9239, D9243, D6010 and 
D6104. You say that these services are needed for your periodontal disease and health. The Plan denied your 
request. The Plan says this dentist is not certified for Medicare and therefore, is not a Medicare-covered 
provider. 
 
 The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), bone replacement graft 
for ridge preservation - per site (D7953), guided tissue regeneration - resorbable barrier, per site (D4266), 
periodontal scaling and root planing - one to three teeth per quadrant (D4342), localized delivery of 
antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4831), 
intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), intravenous moderate 
(conscious) sedation/analgesia  each subsequent 15 minute increment (D9243), surgical placement of implant 
body: endosteal implant (D6010), and bone graft at time of implant placement (D6104) provided on January 
29, 2020, and September 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the records do not indicate that the enrollee needs an intensive therapy 
program with multiple visits from a rehabilitation doctor per week. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the 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 was admitted for pulmonary embolism and stroke and was transferred to skilled nursing on February 1, 
2023. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does 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 this enrollee 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 the IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on June 
21, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance ride 
should not have the copayment since it was necessary. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each one-way Medicare-covered ambulance transport.  
 
You have been asked to pay a $250 copayment for the ambulance services. This item/service falls within the 
ambulance 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 the ambulance 
services provided on June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the back brace provided on September 12, 2022. We 
also decided that the Plan does not have to fully waive the coinsurance for the back brace provided on 
September 12, 2022.  
 
You asked the Plan to waive the coinsurance for the back brace. You say that the provider's office told you 
there would be no charge for the back brace. The Plan says that this cost sharing was charged correctly. 
 
 
 We decided that the Plan has to reduce the coinsurance for the back brace.  
 
The allowed amount for the back brace is $882.72. Your contract with the Plan says that you can only be asked 
to pay 20% coinsurance of the allowed amount for the back brace. You were asked to pay $179.41, when 20% 
coinsurance of the allowed amount is $176.54 ($882.72 allowed amount x 20% coinsurance = $176.54). 
Therefore, we decided that the Plan has to reduce the coinsurance for the back brace provided on September 
12, 2022.  
 
We also decided that the Plan does not have to fully waive the coinsurance for the back brace. 
 
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 20% 
coinsurance for the back brace.  
 
This item/service falls within the prosthetics devices and supplies benefit category. 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 fully waive the coinsurance for the back brace provided on September 12, 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.