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

 
We decided that the Plan does not have to pre-approve Yervoy and Opdivo. 
 
You asked the Plan to pre-approve Yervoy and Opdivo. 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 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 Yervoy and Opdivo. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the combination of nivolumab and 
ipilumumab is not indicated for recurrent non-small cell lung cancer. This enrollee has received first line 
therapy followed by maintenance pembrolizumab. The proposed combination is indicated for 1st line. The 
service 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 Yervoy and Opdivo have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Yervoy and Opdivo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral facet joint injections, cervical or thoracic; third 
and any additional level (64492) for the enrollee. 
 
You asked the Plan to pre-approve the third level. You say that the old fracture is not the source of the 
enrollee's pain. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
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 the third level. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that a third level would exceed utilization criteria and therefore is not 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 the third level have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral facet joint injections, cervical or thoracic; third and any additional level (64492) 
for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 7, 2022 billed with 
codes 81405, 81407, 81406. 
 
You asked the Plan to pay for the genetic testing billed. You say that the enrollee's physician ordered genetic 
testing due to its validated clinical utility in clarifying disease risk. The Plan denied your request. The Plan says 
per Medicare guidelines, it is not appropriate to bill individual CPT codes for a single panel. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 7, 2022 billed with codes 81405, 81407, 81406.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro, Carfilzomib, and Methylprednisolone 
sodium succinate. 
 
You asked the Plan to pre-approve Darzalex Faspro, Carfilzomib, and Methylprednisolone sodium succinate. 
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 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 Darzalex Faspro, Carfilzomib, and 
Methylprednisolone sodium succinate. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found in this case, the record indicates that the enrollee has a diagnosis of recurrent multiple 
myeloma after tandem transplant. The Food and Drug Administration has not stated that the requested drug 
regimen as prescribed is indicated for the enrollee's condition. The Medicare approved cancer drug compendia 
do not contain a supportive citation for the use of the requested drug regimen in the enrollee's clinical situation. 
No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage 
criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex Faspro, Carfilzomib, and Methylprednisolone sodium succinate have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Darzalex Faspro, Carfilzomib, 
and Methylprednisolone sodium succinate.
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 the medical records do indicate that SNF services 
were necessary for the enrollee. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 enrollee does not have documented skilled nursing needs. The enrollee does 
not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplicate x-ray provided to the enrollee on March 10, 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 records submitted do not indicate that two separate services were performed and supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the duplicate CPT code 73030 is not supported in the medical record. Specifically, there is no evidence that two separate imaging services were rendered in this case. 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 a duplicate x-ray provided to the enrollee on March 10, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the acupuncture treatment (97810, 97811) provided on March 10, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the services were rendered by an 
unqualified provider. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at this case file and the Medicare rules. Based on this information, we decided that the Medicare 
rules for coverage of these services have been met. Specifically, the services in this case were performed by a 
licensed acupuncturist who was under the supervision of a nurse practitioner. Therefore, we decided that the 
Plan has to pay for the acupuncture treatment (97810, 97811) provided on March 10, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychosocial rehabilitation (PSR) services. 
 
You asked the Plan to pre-approve PSR services. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 PSR services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on review the records provided you do not require inpatient care for the treatment 
utilizing Psychosocial Rehabilitation Services (PSR) but could be treated on an outpatient basis by your doctor 
along with therapy and therefore is not considered 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 PSR services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve psychosocial rehabilitation (PSR) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this cost is too high, and 
if you had known about it, you would have arranged a different ride. The Plan denied your request. The Plan 
says you were charged this cost sharing 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 ambulance trip. You had 1 ambulance trip(s). The Plan charged you $250 for these 
services. 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on April 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab testing. You say that the doctor's office failed to send in a 
preauthorization form for approval. The Plan denied your request. The Plan says the services were provided 
out-of-network and were not approved in advance. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 lab testing provided on April 8, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency hospital services provided from November 20, 
2019, to December 6, 2019, while traveling outside of the United States. 
 
You asked the Plan to pay for emergency hospital services. You say that the services at issue were needed on 
an emergency basis. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of emergency hospital services have been 
met. Specifically, the case record does not contain proof of payment for the services at issue. Therefore, we 
decided that the Plan does not have to pay for emergency hospital services provided from November 20, 2019, 
to December 6, 2019, while traveling outside of the United States.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathological lab testing of dystrophic toenails provided on 
May 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for lab testing. You say that the enrollee does not come to the lab location so is 
therefore not using out-of-network benefits if the enrollees participating doctor sends the specimen to 
examine. The Plan denied your request. The Plan says the referring physician and rendering provider in this 
case are out-of-network. The Plan also says there were no prior authorization requests made before the services 
were rendered. Additionally, the services were neither urgent nor emergent.  
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 pathological lab testing of dystrophic toenails 
provided on May 16, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the upper complete denture (D5110) and the lower 
complete denture (D5120) provided on April 7, 2022. 
 
You asked the Plan to pay more for the dental items. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the upper complete denture (D5110) and the 
lower complete denture (D5120) provided on April 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on February 21, 
2022, coded as 93042. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit 
exists between codes 12002 and 93042. This PTP edit has a modifier indicator of 1, which indicates modifiers 
associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP 
code edit.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. In this case, this claim cannot be paid due to the 
omission of a required modifier. Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for imaging services provided to the enrollee on February 21, 
2022, coded as 93042.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 14, 2022 billed with 
codes 81408, 81407, 81406, 81161, 81405, 81404, 81403, 81401 and 81329. 
 
You asked the Plan to pay for the genetic testing billed. You say that the enrollee's physician ordered genetic 
testing due to its validated clinical utility in clarifying disease risk. The Plan denied your request. The Plan says 
it is not appropriate to bill individual CPT codes for a single panel. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 14, 2022 billed with codes 81408, 81407, 81406, 81161, 81405, 81404, 81403, 81401 and 81329.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on April 11, 2022, by an out-of-
network (OON) podiatrist. 
 
You asked the Plan to pay for the outpatient visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 outpatient visit provided on April 11, 2022, by 
an out-of-network (OON) podiatrist.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided on April 
29, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that you should not have to 
pay this amount, the Plan should be covering it. The Plan denied your request. The Plan says the copayment 
that was applied was 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 $120 
copayment for radiological diagnostic services, not including X-rays, performed in a physicians office or at a 
free-standing facility.  
 
You have been asked to pay the allowed amount of $60.79, which is less than the $120 copayment for a 
diagnostic ultrasound. A diagnostic ultrasound falls within the Other Outpatient Diagnostic Tests - 
Radiological Diagnostic Services, Not Including X-rays benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided on April 29, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy visits for generalized 
anxiety provided on June 27, 2022, and July 5, 2022. 
 
You asked the Plan to waive the copayment for psychotherapy visits. You say that you were told you would 
have no copayments through the remainder of the year because you met your out-of-pocket maximum. You say 
you are extremely upset by the misinformation and should not be held responsible for the copayments. The 
Plan denied your request. The Plan says the copayment was applied correctly according to your contract. The 
Plan reviewed call history and confirmed that you were mistakenly transferred to Medicare directly instead of 
the Plans Member Service Center when you called to inquire about your coverage. As a result, the Plan says it 
is unknown whether misinformation was 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 $30 
copayment for outpatient mental health care.  
 
You have been asked to pay a $30 copayment each for two psychotherapy visits. Psychotherapy visits fall 
within the outpatient 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 psychotherapy visits for generalized anxiety provided on June 27, 2022, and July 5, 2022.