Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 
You asked the Plan to pre-approve Lucentis. You say that the enrollee needs to switch from Eylea to Lucentis 
due to the fact that she had a recent heart attack. You say that switching to Avastin would not be in the 
enrollee's best interest. The Plan denied your request. The Plan says the records do not show that the enrollee 
has tried the preferred drug or that there are medical reasons that prevent them from using it. 
 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 Lucentis. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug Avastin 
before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. 
There is no documentation provided indicating that the plans required drug 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 Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on May 9, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment as the procedure code is eligible for payment according to Medicare rules. The Plan 
denied your request. The Plan says that required information was not received by the Plan. 
 
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. In this case, the Plan originally denied payment stating that the service is not 
covered by Medicare. The Plan then changed their denial and stated required clinical information was missing 
in order for this claim to process. However, the record does not detail that the Plan made reasonable and 
diligent attempts to obtain clinical information from the provider for the services rendered. Notably, the record 
does not contain evidence of the Plans attempts to reach out to the provider. Therefore, we decided that the 
Plan has to pay for the laboratory services provided on May 9, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. All medically necessary care is being provided in the current 
acute care setting. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service May 12, 
2022, to May 15, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service May 12, 2022, to May 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide for 35 hours a week. 
 
You asked the Plan to pre-approve a home health aide for 35 hours a week. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide for 35 hours a week. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found you primarily 
have custodial needs. Home health services are not medically necessary to supervise you to prevent wandering. 
Therapeutic aide services are not necessary 7 hours per day. Two hours per day are sufficient to meet your 
personal hygiene needs.  
 
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 home health aide for 35 hours a week have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a home health aide for 35 hours a week.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services provided from October 2, 2021, to December 
30, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the billed ambulance transport (A0428) 
was denied because HCPCS code A0380, A0390, A0425, A0435, and A0436 was not paid or identified for the 
same date of service. 
 
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. In this case, the Plan has not provided any evidence to indicate why this claim 
has been denied based on Medicare guidelines. The Plan says the billed ambulance transport (A0428) was 
denied because HCPCS code A0380, A0390, A0425, A0435, and A0436 was not paid or identified for the 
same date of service. However, the Plan provides no evidence that this is based on Medicare criteria. It is the 
burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the ambulance 
services provided from October 2, 2021, to December 30, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart device. 
 
You asked the Plan to pre-approve an Optimizer Smart device. You say that you are not responding to 
medication management and have exhausted or failed conservative and standard of care treatment. You say that 
you are not a suitable candidate for Cardiac Resynchronization Therapy. You say that your symptoms impact 
functional capacity. The Plan denied your request. The Plan says the insertion or replacement of permanent 
cardiac contractility modulation system, including contractility evaluation when performed, and programming 
of sensing and therapeutic parameters; pulse generator with transvenous electrodes is considered unproven. 
 
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 an Optimizer Smart device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found cardiac contractility modulation CCM remains the subject of multiple 
studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify 
clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical 
outcomes and benefit.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Optimizer Smart device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Optimizer Smart device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from February 17, 
2022, to March 10, 2022. 
 
You asked the Plan to pay for the home health care services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the required 
data element, admission/start of care date on the subsequent period of care claim does not match the admission 
date reported on the first period of care NOA claim. Therefore, we decided that the Plan does not have to pay 
for the home health care services provided from February 17, 2022, to March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on March 17, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. 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 laboratory 
services (0037U) provided on March 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have waive the coinsurance for gammagard injections provided on  
January 24, 2022, and February 24, 2022. 
 
You asked the Plan waive the coinsurance for gammagard injections. You say that your out-of-pocket 
maximum had been met. 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 Part B drugs.  
 
 
  
 
 
 
You have been asked to pay $1,082.81 for gammagard injections.  
 
 
Date of Service Service Plan Allowance Cost Per Contract Your 
Responsibility 
January 24, 2022 Gammaguard 
Injection 
$2,784.19 $556.84 $556.84 
February 24, 2022 Gammaguard 
Injection 
$3,733.36 $746.67 $525.97-Met Max            
OOP 
Total    $1,082.81 
 
 
This item/service falls within the Medicare Part B prescription drugs benefit category. At the time these claims 
were processed, your out-of-pocket maximum had not been met. Your out-of-pocket maximum was met with 
the processing of the February 24, 2022 claim. 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 waive the coinsurance for gammagard 
injections provided on January 24, 2022, and February 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endoscopic retrograde cholangiopancreatography (ERCP) 
(procedure code 43261) provided to the enrollee on May 6, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code 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. 
 
In this case, the CPT Code Manual definition of code 43261 is "Endoscopic retrograde 
cholangiopancreatography (ERCP); with biopsy, single or multiple." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report does not 
support separate anatomical area procedures were performed, and therefore this procedure would be inclusive 
to CPT 43271.  Procedure report documents " "Given the bile duct polypoid area and inability to sample via 
EUS safely without bile leak, the decision was made to perform and ERCP. The scope was withdrawn and replaced with the ERCP scope in order to accomplish the maneuver...The lower third of the main bile duct was 
biopsied with a cold forceps for histology."  Therefore modifier XU cannot be verified. 
 
We looked at this coder'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 pay for endoscopic retrograde cholangiopancreatography (ERCP) (procedure code 43261) provided to 
the enrollee on May 6, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that this procedure is medically 
necessary for the enrollee's medical condition. The Plan denied your request. The Plan says that there is no 
evidence requested spinal cord stimulator is being used only as the last resort for chronic intractable pain. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator trial is subject to the criteria 
listed 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 spinal cord stimulator trial. Our 
reviewer says that the requested spinal cord stimulator trial is medically reasonable and necessary. Our 
physician reviewer found that the enrollee is a 71-year-old man with post-laminectomy syndrome. They have 
undergone L2-L3 posterior arthrodesis, instrumentation of L2-L5, L2-L3 laminectomy, Bilateral foraminotomy 
L2-L5. In addition, they have had transforaminal epidural steroid injections, radiofrequency ablation of the 
medial branches and selective nerve root block. They have had transcutaneous electrical nerve stimulator and 
physical therapy. They take MS Contin, Percocet, Gabapentin and Lidoderm patches. They have had their 
diabetes regimen improved. They have also had psychological evaluation and clearance for a spinal cord 
stimulator trial. In this case, the enrollee has failed conservative therapy, and this would be a late or last 
therapeutic intervention as defined by NCD 160.7. The request is medically 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 a spinal cord stimulator trial have been met. Therefore, we decided that the Plan 
has to pre-approve a spinal cord stimulator trial.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that patient is at functional baseline (hospital 
bed bound). Skilled therapy would be required as well as skilled nursing however there is no documentation to 
show that patient would require daily skilled services on an inpatient basis in a skilled nursing home. 
Additionally, the documentation states that patient wishes to transition home with home health care 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 18, 
2022, to July 15, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 18, 2022, to July 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient mental health care stay 
provided from January 26, 2022, to February 14, 2022. 
 
You asked the Plan to waive the copayment for an inpatient mental health care stay. You say that you would 
like to appeal the $1625 copayment because the inpatient hospital services were involuntary, and you would 
also like to request a police investigation. 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 $325 
copayment each day for days 1 to 5 for Medicare-covered hospital care each time you are admitted.  
 
 
  You have been asked to pay a copayment of $1,625 for an inpatient mental health care stay ($325 per day x 5 
days = $1,625). This item/service falls within the Inpatient Mental Health 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 inpatient mental health care stay provided from January 26, 2022, 
to February 14, 2022.  
 
Your complaint about the inpatient stay being involuntary is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.