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

 
We decided that the Plan does not have to pre-approve Keytruda, Carboplatin, Leucovorin calcium, 
Fluorouracil, Docetaxel, and Dexamethasone sodium phosphate. 
 
You asked the Plan to pre-approve Keytruda, Carboplatin, Leucovorin calcium, Fluorouracil, Docetaxel, and 
Dexamethasone sodium phosphate. 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 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 Keytruda, Carboplatin, Leucovorin 
calcium, Fluorouracil, Docetaxel, and Dexamethasone sodium phosphate. Our reviewer says that the services 
are not medically necessary. Our physician reviewer found the requested drugs are not FDA-approved for the 
enrollees diagnosis. The use of the drugs is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda, Carboplatin, Leucovorin calcium, Fluorouracil, Docetaxel, and 
Dexamethasone sodium phosphate have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Keytruda, Carboplatin, Leucovorin calcium, Fluorouracil, Docetaxel, and Dexamethasone sodium 
phosphate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 23, 2020. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim processed at the in-
network level. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until June 15, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on October 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the peripheral artery disease test performed 
on November 1, 2021. 
 
You asked the Plan to waive the copayment for the peripheral artery disease test. You say that you were 
charged for a service that was not performed. 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 $105 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).   
 
 
 
 You have been asked to pay a $90.44 copayment for the peripheral artery disease test because the allowed 
amount for this service is less than $105. 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 
the peripheral artery disease test performed on November 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
October 3, 2022, and October 7, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford the 
cost-sharing for these services. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each one-way Medicare-covered ground ambulance trip. 
 
You have been asked to pay a $500 copayment for the ambulance services ($250 copayment x 2 services = 
$500). These items/services fall within the ambulance services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the ambulance services provided on October 3, 2022, and October 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that it is the responsibility of the facility to obtain 
authorization. The Plan denied your request. The Plan says there is no preauthorization for the services 
rendered. 
 
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 July 20, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 29, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. 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). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the fundus photography (92250) provided on September 13, 2022. 
 
You asked the Plan to pay for the fundus photography. You say that this scan should be covered, which is part 
of the standard exam coverage. You also say that your mom has a genetic macular degeneration, which 
typically happens with age but could also happen earlier in life, and you want to prevent any vision loss. The 
Plan denied your request. The Plan says that this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan denied this fundus photography as not a covered service. 
We find that this service is considered to be a Medicare-covered outpatient diagnostic test. It is the burden of 
the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so 
we must find in your favor. Therefore, we decided that the Plan has to pay for the fundus photography (92250) 
provided on September 13, 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 waive the copayment for inpatient hospital stay from August 29, 
2022, through September 4, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you paid your $250 
copayment for being admitted. You say that you did not realize the copayment would be charged on a daily 
basis. 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 $250 
copayment for each day for days 1 to 5 for Medicare-covered hospital care each time you are admitted. $0 
copayment for additional Medicare-covered days.  
 
  You have been asked to pay $1,000 copayment for the inpatient hospital stay. The allowed amount is $1,250 
($250 x 5 days = $1,250 - $250 (payment) = $1,000 balance). Inpatient hospital stay 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 stay from 
August 29, 2022, through September 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that you would like the Plan 
to reconsider your request. The Plan denied your request. The Plan says this item is not covered by Medicare or 
the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The rules say a fluid circulating cold pad with pump (E0218) will be 
denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a 
fluid circulating cold pad with pump (E0218).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure (64628). 
 
You asked the Plan to pre-approve an intracept procedure. You say that this service is medically necessary. The 
Plan denied your request. The Plan says this service is considered experimental. 
 
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 intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided on August 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services billed. 
 
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 G0482 is Drug test(s), definitive, 15-21 drug class(es), 
including metabolite(s). 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show 
testing for 15 or more drug classes. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(G0482) provided on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says there is no authorization on file from the primary care 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 an office visit provided on September 15, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humalog Kwikpen. 
 
You asked the Plan to pre-approve Humalog Kwikpen. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate 
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Humalog Kwikpen.  
 
Benefits for Humalog Kwikpen may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on September 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services provided on July 30, 2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the billing. The Plan 
denied your request. The Plan says that the code is not covered for this provider type. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient. We find that CPT code 99285 is supported. The code was billed with an 
emergency room place of service code, and the services were performed by an emergency physician. Based on 
this information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, 
we decided that the Plan has to pay for the emergency room services provided on July 30, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on September 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport and ground mileage provided on May 24, 2022, to June 9, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
mileage. You say that the medical records provided support the need for the requested ambulance transports. 
The Plan denied your request. The Plan says the ambulance transports were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance service, basic life support, 
non-emergency transport and ground mileage. Our reviewer says that the services were not medically 
necessary. Our physician reviewer found the transportation via ambulance from the medical facilities to the 
enrollee's residence was not medically necessary on May 24, 2022, May 28, 2022 and June 9, 2022.  
 The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance 
in order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van, 
wheelchair van, private car, taxi) without endangering the enrollee's 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 the ambulance service, basic life support, non-emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
basic life support, non-emergency transport and ground mileage provided on May 24, 2022, to June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bifocal glasses and polycarbonate lens provided on 
November 2, 2022. 
 
You asked the Plan to pay for the bifocal glasses and polycarbonate lens. You say that you disagree with the 
denial and would like the plan to reconsider. The Plan denied your request. The Plan says the maximum 
allowed under the benefit was exceeded.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services with a $200 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $200 towards the services, which 
exhausted the benefits. Based on this information, we decided that the Plan's rules for coverage of the bifocal 
glasses and polycarbonate lens have not been met. Therefore, we decided that the Plan does not have to pay for 
the bifocal glasses and polycarbonate lens provided on November 2, 2022.