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

 
We decided that the Plan has to pre-approve Abraxane infusions. 
 
You asked the Plan to pre-approve Abraxane infusions. You say that the provider wishes to treat the enrollee 
with Abraxane rather than Taxol in order to not exacerbate the neuropathy further. The Plan denied your 
request. The Plan says that step therapy criteria have not been met, medical necessity has not been established, 
and authorization for Abraxane cannot be provided. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Abraxane infusions. Our reviewer 
found that the Plan requires a trial of Paclitaxel before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drug. Our reviewer found that there is documentation provided 
indicating that the Plans required drug could have adverse effects for the enrollee. Our physician reviewer also 
found that Taxol/Paclitaxel is likely to exacerbate the enrollees neuropathy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abraxane infusions have been met. Therefore, we decided that the Plan has to 
pre-approve Abraxane infusions.  
 
  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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyramza infusions to be given with Abraxane infusions. 
 
You asked the Plan to pre-approve Cyramza infusions. You say that this combination is proven to be effective 
in patients with gastric cancer. The Plan denied your request. The Plan says criteria for medical necessity have 
not been established and coverage for Cyramza infusions in combination with Abraxane cannot be authorized. 
 
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 Cyramza infusions. Our reviewer says 
that Cyramza infusions are not reasonable and necessary for the enrollee. Our physician reviewer found the 
record indicates that the enrollee has a diagnosis of metastatic gastric adenocarcinoma. The FDA has not stated 
that the requested drug regimen is indicated for the enrollee's condition. Our reviewer found that 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. Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and 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 Cyramza infusions have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Cyramza infusions to be given with Abraxane infusions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150) and intraoral - complete series of radiographic images (D0210) provided on February 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you called the Plan, and you were told the 
services would be covered even though they were over the limit rules. The Plan denied your request. The Plan 
says your benefit for the requested item or service has already been exhausted. 
 
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. This benefit includes the 
requested comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of 
radiographic images (D0210) but each is limited to one procedure every three plan years. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested comprehensive oral evaluation - new or established patient (D0150) and 
intraoral - complete series of radiographic images (D0210) was exhausted on date of service January 07, 2020. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - new or 
established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided on 
February 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that the services requested are 
medically necessary. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 magnetic resonance imaging (MRI). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the information 
provided is insufficient to make a decision on the medical necessity of the requested MRI of the cervical spine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance imaging (MRI) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 26, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on 
February 21, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you disagree with the 
copayment. 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 $30 
copayment for outpatient diagnostic tests/Medicare-covered non-radiological diagnostic services.  
 
You have been asked to pay a $30 copayment for outpatient diagnostic tests. This item/service falls within the 
outpatient diagnostic tests/Medicare-covered non-radiological diagnostic 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 outpatient diagnostic tests provided on February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit provided on April 1, 2022 
 
You asked the Plan to waive the copayment for specialist visit. 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 $60 
copayment for physician/practitioner services, including doctors office visits.  
 
You have been asked to pay $55.47 which is less than the $60 copayment for specialist visit. This item/service 
falls 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 copayment for specialist visit provided on April 1, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on May 12, 2022, from 
an out-of-network (OON) provider 
 
You asked the Plan to pay for the hearing aids. You say that you called the Plan to ask about your coverage for 
hearing aids, and you were given the mailing address to send your request for payment from the OON provider. 
You also say when you spoke to the OON provider, you were advised you had to pay first, then the insurance 
would pay you back and you agreed to that. The Plan denied your request. The Plan says you self-referred to 
the OON provider. The Plan also says that no misinformation has been given by the Plan, as on each call you 
were advised and sent over to the Plan's Hearing department to further discuss hearing aid benefits. 
 
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 for 
hearing aids only when you use the Plan's approved hearing aid vendor for your hearing aid benefits. 
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5261) purchased on May 12, 2022, from an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 4 additional units of procedure code 87798 billed for date of 
service March 30, 2022. 
 
You asked the Plan to pay for procedure code 87798. You say that you would like the additional units billed of 
this service to be paid. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 17 units of this 
code, exceeding the MUE. 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 for payment for the additional units 
of 87798. Our reviewer found that you did not provide all the required evidence showing that the excess units 
were actually provided, were correctly coded, and were medically necessary. Based on this information, we 
decided that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided 
that the Plan does not have to pay for 4 additional units of procedure code 87798 billed for date of service 
March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the accessories (E2311, E2313, E2377 and K0108 X3). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The electrical connection between the 
wheelchair controller and two or more motors (E2311, expandable controller (E2377) and harness (E2313) 
cannot be approved. There is a not a medical need to control these power options through the joystick. The 
enrollee is noted to have 3/5 strength in the distal bilateral upper extremities. The enrollee is independent with 
feeding, they are setup with dressing, grooming, bathing, meal prep, toileting. The enrollee's upper limb 
strength and function are adequate for the enrollee to be able to control the power options using their own 
switches which are included in the allowance of these power options. There is a request for K0108 calf pad and 
assembly. This is properly coded E0995 calf pads replacement. The full description of this code is E0995, 
wheelchair accessory, calf rest/pad, replacement only, each. These are for replacement items. Calf pads are 
unbundled from the requested wheelchair. Replacement items cannot be approved with initial issue. There is a 
request for K0108 foot plate/bracket assembly. These are parts that are miscoded; K0108 must not be used for 
items that have a specific HCPCS code. There is a request for K0108 foot plate bracket assay. The correct 
codes for footplates are K0040, K0041 or K0042. A request for footplates that meets the enrollee's needs and 
Medicare guidelines can be reviewed if submitted. Therefore, we decided that the Plan does not have to pre-
approve the accessories (E2311, E2313, E2377 and K0108 X3).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 7, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from January 7, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from January 
7, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of January 7, 2023, forward. Our physician reviewer found the enrollee 
did not require inpatient mental health treatment beyond January 7, 2023, as she was not a danger to herself or 
others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment 
was taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from January 7, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 7, 
2023, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve the occlusal guard  hard appliance, full arch (D9944). You say that the 
guard with be beneficial to prevent future damage to your teeth and alleviate pain, not only in the short term 
from the tension in your jaw and headaches. The Plan denied your request. The Plan says this service is not 
covered under the benefit package. 
 
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 pre-approve an 
occlusal guard  hard appliance, full arch (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a post operative office visit (D0171) provided on September 
14, 2022. 
 
You asked the Plan to pay for an office visit. You say that you disagree with the denial for the post operative 
office visit. The Plan denied your request. The Plan says a post operative office visit (D0171) is not covered by 
your dental 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 item or service is not 
among those covered under this benefit.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for a post operative office visit (D0171) provided on 
September 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided 
on September 14, 2021, to October 15, 2021. 
 
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree 
with the copayment. 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 $40 
copayment per visit for outpatient rehabilitation services.  
 
You have been asked to pay a $40 copayment per visit for outpatient rehabilitation services. The total amount 
you are being asked to pay is $80 ($40 x 2 visits = $80). This item/service falls within the outpatient 
rehabilitation 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 outpatient 
rehabilitation services provided on September 14, 2021, to October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ear mold/insert (V5264) and hearing aid (V5298) 
provided on August 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ear mold/insert and hearing aid. You say that you cannot use the in-network 
company for your hearing aid because your hearing loss is not age related, but is because of a medical 
condition. The Plan denied your request. The Plan says it was confirmed that you have not set up a hearing 
profile and there was no provider assigned. The Plan also says you received these services from an OON 
provider. 
 
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 for 
hearing aids only when you use the Plan's approved hearing aid vendor to use your hearing aid benefits.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the ear mold/insert and hearing aid have not been met. Therefore, we decided that the Plan does not 
have to pay for the ear mold/insert (V5264) and hearing aid (V5298) provided on August 11, 2022, by an out-
of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and can be 
managed at an LTACH level. You say that the enrollee is stabilized but is requiring more time to be weaned off 
the oxygen and receive therapy to return to their prior level of function to return home to their family. The Plan 
denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee can 
receive the care they need in the current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is improving but still is unstable and only requires short-term acute 
care at the current facility until they are more stable. The enrollee does not require services at the LTACH that 
are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.