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

 
We decided that the Plan does not have to pay for the hospital discharge day management services provided on 
November 29, 2021. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management services provided on 
November 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device. 
 
You asked the Plan to pre-approve the insertion of stabilization device. You say that the enrollee has suffered 
from this condition for 10 years and has failed 26 months of conservative approaches to treatment. You say that 
recommend this minimally invasive procedure when conservative treatment has failed and the request should 
be approved. The Plan denied your request. The Plan says there are not enough studies to show that Vertiflex 
Superion is safe and effective to treat back 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 insertion of stabilization device. 
Our reviewer says that the Vertiflex device is not considered medically reasonable and necessary in this case.  
 
  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 insertion of stabilization device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of stabilization device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Necitumumab (J9295), Cisplatin (J9060), and 
Gemcitabine (J9201). 
 
You asked the Plan to pre-approve Necitumumab, Cisplatin, and Gemcitabine. The Plan denied your request. 
The Plan says the use of Necitumumab (Portrazza), Cisplatin (Platinol), and Gemcitabine (Gemzar) is not FDA 
approved as second-line treatment for this type of cancer. The Plan also says that there is lack of support for its 
use in the Medicare references. 
 
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 Necitumumab, Cisplatin, and 
Gemcitabine. Our reviewer says that Necitumumab, Cisplatin, and Gemcitabine are not medically reasonable 
and necessary. Our physician reviewer found the Food and Drug Administration (FDA) has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Our reviewer 
found that no literature from Medicare approved cancer journals were submitted for review. The elements of 
the coverage criteria are not satisfied. Our physician reviewer also found that 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 Necitumumab, Cisplatin, and Gemcitabine have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Necitumumab (J9295), Cisplatin (J9060), and Gemcitabine 
(J9201).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for out-of-area services provided from February 11, 2022, to February 25, 
2022. 
 
You asked the Plan to pay for out-of-area services. You say that you were taken to the emergency room for 
stone pain. The Plan denied your request. The Plan says that there was no prior authorization for services 
outside the Plan's service area. 
 
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. Urgent out-of-area services would not require authorization. The Plan has not 
submitted medical records to support their denial that the out-of-area services were not urgent. 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 out-of-area services provided 
on February 11, 2022, to February 25, 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 pay for the COVID-19 vaccine administered on November 18, 2021. 
 
You asked the Plan to pay for the COVID-19 vaccine. You say that payment should be made for the COVID-
19 vaccine. The Plan denied your request. The Plan says payment must be made for the COVID-19 vaccine 
through Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Pursuant to CMS guidance Medicare payment for COVID vaccinations administered during calendar years 
2020 and 2021 to MA beneficiaries will be made through the Medicare Fee for Service program. Based on this 
information, we decided that Medicare rules for coverage of the COVID-19 vaccine have not been met. 
Therefore, we decided that the Plan does not have to pay for the COVID-19 vaccine administered on 
November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the enrollee does not meet the Medicare criteria for this service. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint interventions may be covered under 
certain circumstances. 
 
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 facet joint injections. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician 
reviewer found the standard of care does not include repeated medial branch blocks. After achieving success, 
radiofrequency ablation (RFA) should be the next step. Prior facet injections have provided excellent pain 
relief but there is no documentation as to why RFA is not the next step. Therefore, this request is not medically 
reasonable or 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to waive the copayment for medical vision services (99214, 92134, 92202) 
provided by an ophthalmologist on February 23, 2022. 
 
You asked the Plan to waive the copayment for the vision care. You say that there should be a $0 copayment 
for these services. The Plan denied your request. The Plan says that this claim was processed correctly. The 
enrollee is responsible for a $15 copayment for each Medicare-covered eye exam service. The enrollee is being 
asked to pay $10.84 for the exam for a total of $25 for the services performed by this provider on February 23, 
2022. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The contract with the Plan clearly says that enrollees must pay a $0 
copayment for Medicare-covered diagnosis and treatment for diseases and conditions of the eye.  
 
We looked at the contract with the Plan, the appeal request, and the records provided. Although it is clear from 
the appeal request that the enrollee is disputing a $25 copayment that was assessed for the services provided on 
February 23, 2022, the Plans denial only addresses the $10.84 amount which was applied to the office visit 
billed with procedure code 99214 (which is incorrectly referred to by the Plan as an eye exam). The Plan does 
not clarify or explain why a $25 copayment was assessed for this claim. The Plans denial only states that this 
claim (specifically code 99214) was processed correctly as the contract states that enrollees are required to pay 
a $15 copayment for Medicare-covered eye exams. However, none of the services at issue were billed 
specifically as eye exams, but rather as an office visit and diagnostic ophthalmic procedures. Based on the 
contract with the Plan, the enrollee cannot be asked to pay more than $0 for Medicare-covered services for 
diagnosis and treatment for diseases and conditions of the eye. Therefore, we decided that the Plan has to waive 
the copayment for medical vision services (99214, 92134, 92202) provided by an ophthalmologist on February 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that there is little evidence in the medical literature to suggest that this 
is an appropriate procedure for the enrollee's back 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The intracept 
procedure is experimental. More research is needed. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these services. 
 
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 the Intracept procedure for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enbrel SureClick. 
 
You asked the Plan to pre-approve Enbrel. The Plan denied your request. The Plan says this drug is not eligible 
for coverage under the Part B benefit. 
 
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 Enbrel SureClick.  
 
 
 Benefits for Enbrel 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Via Disc allograft services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatment. The Plan denied your request. The Plan says this is not an accepted standard of practice for the 
treatment of back 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 the enrollee has chronic low back pain and leg pain which has not been adequately 
controlled with medications, injections and a spinal cord stimulator, although the stimulator does help with the 
leg pain. Magnetic resonance imaging (MRI) of the spine demonstrates scoliosis, multilevel disc disease, spinal 
stenosis, facet arthrosis and ligamentum flavum hypertrophy with endplate sclerosis and Schmorl's nodes. The 
requested service is an experimental/investigational procedure. Therefore, the request is considered not 
medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Via Disc allograft services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an annual gym membership. 
 
You asked the Plan to pre-approve an annual gym membership. You say that you cannot physically lift weights 
or walk so you need the water/pool to help you work out and stay healthy due to bad legs. The Plan denied your 
request. The Plan says gym memberships are not covered, either directly or via reimbursement, with your Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits.  
 
The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to pre-
approve an annual gym membership.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 36245, 36247, 35372 and 75736. We decided that the 
Plan does not have to pay for procedure code 75710.  
 
You asked the Plan to pay for procedure codes 36245, 36247, 35372 and 75736. The Plan denied your request. 
The Plan says that procedure codes 36245, 36247, 35372 and 75736 are not supported by the medical records 
submitted. The Plan also says that procedure code 75710 is considered inclusive to procedure code 35371. 
 
We decided that the Plan has to pay for procedure codes 36245, 36247, 35372 and 75736.  
 
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 has not forwarded any medical records to support their 
denial of this claim. 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 procedure codes 36245, 36247, 35372 and 75736.  
 
We also decided that the Plan does not have to pay for procedure code 75710. 
 
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 75710 
is a column II code to column I code 35371. CPT code 75710 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 75710. 
 
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 intracept for treatment of the member's back pain (CPT 
code 64628). 
 
You asked the Plan to pre-approve the services. You say that the services are 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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intracept procedure 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 intracept for 
treatment of the member's back pain (CPT code 64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on October 5, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says genetic testing 
procedures submitted with code 81448 are unlikely to impact therapeutic decision-making in the clinical 
management of the patient. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services provided on October 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. You say that CT scan showed concern for disease progression. 
The Plan denied your request. The Plan says the clinical value in the setting of disease progression has not been 
demonstrated. 
 
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. Our physician reviewer 
found that the enrollee has metastatic non-small cell lung cancer. The requested use of Keytruda is not FDA-
approved for the enrollee's diagnosis without ALK and EGFR testing. The use is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. The requested 
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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pembrolizumab (Keytruda).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that in-network providers do not show the same 
level of care. The Plan denied your request. The Plan says there are in-network providers available to provide 
care. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial comprehensive nursing facility assessment (99306) 
provided September 17, 2020. 
 
You asked the Plan to pay for the nursing facility care. You say that you are appealing the denial of claim for 
services provided. The Plan denied your request. The Plan says Original Medicare would be responsible for 
payment of all Medicare covered services related or unrelated to the members terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the initial comprehensive nursing facility assessment (99306) 
provided September 17, 2020.