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

 
We decided that the Plan does not have to pre-approve durvalumab (Imfinzi). 
 
You asked the Plan to pre-approve Imfinzi. You say that the enrollee is not a candidate for chemotherapy. The 
Plan denied your request. The Plan says the request does not meet coverage criteria. 
 
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 Imfinzi. Our physician reviewer found 
that the enrollee has well differentiated intrahepatic cholangiocarcinoma. The requested use of Imfinzi is not 
FDA approved as a single agent but in combination with gemcitabine and cisplatin. Also, there is no 
documentation of staging or if the cancer is resectable or not. The requested use is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not 
listed as not indicated, not supported or not recommended in any of the compendia. The documentation does 
not 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 Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve durvalumab (Imfinzi).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional visits with a Naturopathic doctor. 
 
You asked the Plan to pre-approve additional visits. You say that limiting provider types is misleading and 
illogical. The Plan denied your request. The Plan says additional visits beyond the allowed 6 Naturopathic 
visits are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of additional visits have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional visits with a Naturopathic doctor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 22, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 80048, 80076, 84436, and 84479 provided on May 2, 
2022. 
 
You asked the Plan to pay for codes 80048, 80076, 84436, and 84479. The Plan denied your request. The Plan 
says the codes are not separately payable. 
 
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 80048, 
and 80076 are column II codes to column I code 80053 with a modifier indicator of 0. We also found that 
84436 and 84479 are column II codes to column I code 84439 with a modifier indicator of 0. The column II 
codes are 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 codes 80048, 80076, 84436, and 84479 provided on May 2, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires direct supervision and 
management. The Plan denied your request. The Plan says based on Medicare guidelines the inpatient 
rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
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 clinical documentation shows the enrollee to have complex functional 
impairments and wound care needs however there is no documentation specified to show that the enrollee 
would be able to tolerate fifteen hours of therapy per week. There are no complex nursing or rehabilitation 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are still having trouble moving around and you 
need rehabilitation. The Plan denied your request. The Plan says admission to the IRF was denied as not 
meeting criteria, is not medically necessary, and a lower level of care might be appropriate. Skilled nursing 
facility level of care was offered. 
 
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 clinical documentation shows that you have functional impairments however 
there are no complex functional impairments specified thus would not be expected to require intense therapy or 
interdisciplinary team management of rehabilitation in an IRF setting. There are no complex nursing or 
rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is below baseline and requires assistance 
with activities of daily living (ADL) and mobility. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary. 
 
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 as of December 13, 2022, the enrollee was modified independent with bed 
mobility and requiring minimal assistance with transfers and ambulating 10 feet with a walker. The enrollee has not had a significant change in their baseline medical conditions or an acute neurological change and does 
not require the intensity of rehabilitation physician oversight provided in the acute inpatient rehabilitation 
setting. While the enrollee would likely benefit from therapy, they do not require the intensity of therapies 
provided on acute inpatient rehabilitation. 
 
Therefore, the acute inpatient rehabilitation admission is 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on August 5, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you are disputing the share cost. 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 $180 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $180 copayment for CT scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for CT scan provided on August 5, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy visits provided on August 05, 2022. 
 
You asked the Plan to pay for physical therapy visits. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s).there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. The office that 
referred the beneficiary was also out-of-network. Therefore, we decided that the Plan does not have to pay for 
physical therapy visits provided on August 05, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular revascularization services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says it is 
unlikely that the enrollee has a circulation problem that would cause pain. 
 
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 requested services. Our physician 
reviewer found that there is no documentation suggesting limb threat. The enrollees leg pain is described as 
bilateral despite minimal disease identified on the right. He has a history of bilateral knee surgeries. The 
description of the enrollees symptoms is quite limited. It is not clear that the enrollee is having lifestyle 
limiting symptoms that can be attributed to arterial occlusive disease. The documentation shows that the 
enrollees leg pain is improving. There do not appear to be concerted efforts at conservative treatment.  
Therefore, in the setting of what is described as improving symptoms without evidence of limb threat, the 
documentation does not support the medical necessity of the procedures in question. 
 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovascular revascularization services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an extraction of an erupted tooth (D7210) and a maxillary partial 
denture (D5213) provided on August 23, 2022. 
 
You asked the Plan to pay for an extraction of an erupted tooth (D7210) and a maxillary partial denture 
(D5213). You say that you are disabled with a fixed income. The Plan denied your request. The Plan says that 
the calendar year maximum has been reached. The Plan also says that the plan had already paid out the 
member's $2,500 yearly dental maximum. 
 
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. The Plan covers an extraction 
of an erupted tooth (D7210) and a maxillary partial denture (D5213) when the services are medically necessary 
and reasonable. 
 
We looked at the file, and Medicare and Plan rules. The Plan rules say that they have no annual maximum 
amount for supplemental dental services. Based on this information, we decided that the Plan's rules for 
coverage of an extraction of an erupted tooth (D7210) and a maxillary partial denture (D5213) have been met. 
Therefore, we decided that the Plan has to pay for an extraction of an erupted tooth (D7210) and a maxillary 
partial denture (D5213) provided on August 23, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (PBT). 
 You asked the Plan to pre-approve proton beam therapy. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says this procedure is associated with a clinical trial that the 
enrollee is enrolled in; therefore, the Plan is not responsible for coverage. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve proton beam therapy as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve proton beam therapy (PBT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on July 27, 
2022, to July 30, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are disputing the share 
cost. 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 $325 
copayment per day for days 1 to 5 for inpatient hospital care. This inpatient hospital stay lasted 3 days, 
resulting in a copayment amount of $975 ($325 per day for 3 days = $975). 
 
You have been asked to pay $325 copayment per day for days 1 to 5 for inpatient hospital care. This 
item/service falls within the inpatient hospital 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 inpatient hospital care provided on July 27, 2022, to July 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 27, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says this service required 
a prior authorization. 
 
We are remanding this issue back to the Plan for reprocessing. Medicare rules say that a non-contract provider 
can make an appeal request only when it has agreed to waive its right to payment from the enrollee. The rules 
further say that if a non-contract provider files a request for reconsideration of a denied claim without a waiver 
of liability form, the Plan must make and document reasonable efforts to obtain the waiver of liability form. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Parts C & D 
Enrollee Grievances, Organization/Coverage Determinations, and Appeals Grievance Manual, Section 50.9. 
 
In this case, the case file contains an invalid waiver of liability form. The record does not show that the Plan 
made any attempts to cure the defect. Therefore, we are dismissing the case and referring this issue back to the 
Plan. The Plan should provide the appellant with a waiver of liability form. 
 
Once a valid waiver is received by the Plan, the Plan should complete the plan level review. If The Plan 
decides it will not pay for the services provided, the Plan will send the case back to us as a new appeal. A new 
case number will be assigned. 
 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on August 30, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that the records support the services. The Plan denied 
your request. The Plan says services must and can be obtained from an in-network provider. 
 
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 physical therapy services provided on August 
30, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a binaural, digital hearing aid (V5261) provided on June 7, 
2022. 
 
You asked the Plan to pay for a binaural, digital hearing aid (V5261). You say that you have never used your 
insurance on any hearing benefits. The Plan denied your request. The Plan says the provider applied the 
member's $500 benefit to the order. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays $500 
combined in- and out-of-network maximum benefit coverage amount for batteries and each hearing aid (all 
types) up to 1 per ear every 3 years.  
 
  We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of a binaural, digital hearing aid (V5261) have not been met. Therefore, we 
decided that the Plan does not have to pay for a binaural, digital hearing aid (V5261) provided on June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 3, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81291, 81328, 81355, 0031U, 0032U, 0033U and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was reported correctly and 
should be paid. The Plan denied your request. The Plan says panel testing should be billed using one CPT code 
on the claim. 
 
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 3, 2022, billed with codes 81227, 81230, 81231, 81232, 81291, 81328, 81355, 0031U, 0032U, 0033U 
and 81479.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 7, 2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976.  
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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 7, 2022.