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

 
We decided that the Plan has to pre-approve nivolumab and relatlimab-rmbw (Opdualag). 
 
You asked the Plan to pre-approve Opdualag. The Plan denied your request. The Plan says that since Opdivo 
did not help, Opdualag may not work for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Opdualag. Our physician reviewer 
found that the enrollee has metastatic melanoma. The requested use of Opdualag is not FDA-approved for the 
enrollee's diagnosis. However, the use is supported by clinical research that appears in a CMS-approved 
medical journal, the Journal of Clinical Oncology 2017, Volume 35, Issue 15. The requested use is not listed as 
not indicated, not supported or not recommended in any of the compendia. The documentation does support 
that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdualag have been met. Therefore, we decided that the Plan has to pre-
approve nivolumab and relatlimab-rmbw (Opdualag).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed. 
 
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 the Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (92250) provided on May 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the submitted records 
do not show evidence of 92250 being performed. 
 
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 92250 is "Fundus photography with interpretation and 
report". 
 
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 use of code 92250 is 
not supported by the records provided. Our reviewer found that the medical record does not include 
interpretation and report for fundus photography. Therefore, this procedure cannot be verified as performed. 
 
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 the services (92250) provided on May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve K3 prosthetic components. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that K3 prosthetic components are covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has multiple medical 
comorbidities, including back and right knee pain that requires a brace. He has been using a power wheelchair 
which was approved due to impaired activity tolerance from his cardiac condition. The documentation does not 
support he requires K3 components. He is not participating in high impact activities that require the shock 
reducing pylon. The requested components exceed his medical need. 
 
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 K3 prosthetic components.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services to return to their 
prior level of functioning. The Plan denied your request. The Plan says the enrollee does not have complex 
rehabilitation, medical, and nursing needs. The enrollee does not need to be assessed medically and 
functionally face to face by a rehabilitation doctor at least 3 days per week. The enrollee does not need 3 hours 
of therapy per day or 15 hours per week. The enrollee's rehabilitation needs do not require an intensive team 
approach. The enrollee's needs can be met in a lower level of care like a skilled nursing facility. 
 
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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or 
documented. The enrollee does not need 3 hours a day or 5 days a week of therapies. 
 
Documentation does not support the medical necessity due to lack of medical complexity for admission to an 
IRF. While the enrollee would benefit from physical therapy and occupation therapy the enrollee's 
rehabilitation needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing 
facility. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on January 4, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that authorization is not required for the 
services provided. The Plan denied your request. The Plan says the rendering provider is an OON provider and 
there was no referral from an in-network provider or an approved authorization. Also, the service rendered was 
not urgent or 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 the home health services provided on January 4, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for subsequent hospital care (code 99233) provided on November 18, 
2021. 
 
You asked the Plan to pay for subsequent hospital care. You say that this was billed as a corrected claim to 
change code 99232 to code 99233. The Plan denied your request. The Plan says that the denial of payment for 
this service is correct, because code 99233 has a Procedure-to-Procedure (PTP) edit with code 99232 so is not 
separately payable when billed on the same day. 
 
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. Medicare rules say that providers must report services correctly. Providers must report services with 
the appropriate CPT code. 
 
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, we have confirmed that code 99233 is a Column I code to Column 
II code 99232. The Procedure-to-Procedure (PTP) edit for these codes is 0, meaning that this edit cannot be 
bypassed regardless of the code modifiers used. This means that - when billed on the same date of service - 
code 99233 is payable and code 99232 is not separately payable. Therefore, by paying code 99232 and denying 
payment for code 99233 the Plan has processed this PTP edit in reverse. You have requested payment of code 
99233 in lieu of payment for code 99232, which is appropriate according to the Medicare billing and coding 
guidelines. The Plan has provided no other evidence or rationale to support a denial of payment for code 
99233. Therefore, we decided that the Plan has to pay for subsequent hospital care (code 99233) provided on 
November 18, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a screening virtual colonoscopy for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that screening computed tomographic colonography 
(CTC) is nationally non-covered.  
 
Colonoscopy with computed tomography (CT) is not covered at this time. 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 a screening virtual colonoscopy for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rhythm electrocardiogram provided to the enrollee on 
November 20, 2021. 
 
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 provider did not bill as required by Medicare coding regulations. 
 
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 93042 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the rhythm electrocardiogram provided to the enrollee on November 20, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis procedures to be provided by an OON provider. 
 
You asked the Plan to pre-approve dialysis procedures. You say that you do not want to leave the center since 
you consider the staff your family and the center is next to your home. The Plan denied your request. The Plan 
says you must receive care from a network provider. The information received or obtained, does not show that 
transferring your hemodialysis service from one provider to another will affect your health or your condition, 
or that you will need to remain with the current provider for reasons of time and distance from the 
recommended facility. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
dialysis procedures to be provided by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) and occupational 
therapy (OT) services from May 31, 2022, to discharge. 
 
You asked the Plan to pre-approve additional skilled therapy services. You say that the enrollee requires 
additional therapy sessions. You also say that they are in no condition to be discharged. The Plan denied your 
request. The Plan says the additional services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 additional skilled therapy services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the provided documentation indicates neurological 
impairments. The reviewer also found that there was no medically specific timeframe being requested. 
Therefore, the reviewer found that the requested skilled therapy services are not 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 additional skilled therapy services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional physical therapy (PT) and occupational therapy (OT) 
services from May 31, 2022, to discharge.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for follow up surgery provided on April 12, 
2022. 
 
You asked the Plan to waive the copayment for follow up surgery. You say that this should be waived since it 
was a follow up to surgery that wasn't done right the first time. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $320 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center.  
 
 
 
 
 You have been asked to pay $250 which is less than the standard $320 copayment for follow up surgery. 
Surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for follow up 
surgery provided on April 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four home physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that physical therapy is really helping, and it is 
making you feel better. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional visits are not medically necessary based on the 
review of the documentation by the provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve four home physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for office visits and injections provided on 
March 22, 2022, to March 29, 2022. 
 
You asked the Plan to waive the cost share for office visits and injections. You say that this should be covered. 
The Plan denied your request. The Plan says the cost share applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs and $25 copayment for specialist visits.  
 
 
 
 You have been asked to pay $125.94 total for office visits and injections. Injections fall within the Medicare 
Part B Prescription Drugs benefit category. Specialist office visits fall within the Physician/Practitioner 
Services, Including Doctors Office Visits 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 office visits and injections provided on March 22, 2022, to March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denied claim. The Plan denied 
your request. The Plan says the rendering provider is an OON provider and there was no referral from an in-
network provider or an approved authorization. Also, the service rendered was not urgent or 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 an office visit provided on January 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hearing exam provided on March 21, 2022. 
 
You asked the Plan to waive the copayment for hearing exam. You say that you shouldn't be charged extra for 
the hearing exam. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $20 
copayment for each Medicare covered diagnostic hearing exam.  
 
You have been asked to pay $16.24 which is less than the standard $20 copayment for hearing exams. Hearing 
exams fall within the Hearing 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 hearing exam provided on March 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman device. 
 
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 services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Minuteman device is 
considered experimental in nature, as more research is needed to show its efficacy. The services are therefore 
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 a Minuteman device.