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

 
We decided that the Plan does not have to pre-approve Neulasta (J2506). 
 
You asked the Plan to pre-approve Neulasta. You say that Neulasta is medically necessary. The Plan denied 
your request. The Plan says a trial of Zarxio is required before alternatives can be considered. 
 
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 Neulasta. Our reviewer says that 
Neulasta is not medically necessary. Our physician reviewer found the record does not show a trial of the plan 
preferred drug or any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta (J2506).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Opdivo (nivolumab) treatments. 
 
You asked the Plan to pre-approve the Opdivo treatments. You say that this is prescribed for an FDA-approved 
indication due to recurrence after chemoradiation with a platinum-containing drug. The Plan denied your 
request. The Plan says that since this is the first recurrence of disease, Opdivo is not considered a first-line 
treatment at this time. 
 
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 the Opdivo treatments. Our reviewer 
says that the requested drug treatment is considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has recurrent head/neck cancer after initial treatment with radiation and 
cisplatin-chemotherapy. Per the National Comprehensive Cancer Network (NCCN) compendia, nivolumab is 
indicated for systemic therapy as a single agent subsequent-line option for nasopharyngeal cancer if previously 
treated, recurrent or metastatic non-keratinizing disease in patients with performance status (PS) of 0-2 for 
recurrent/persistent disease with distant metastases and unresectable locoregional recurrence, unresectable 
second primary, or unresectable persistent disease with prior radiation therapy. The criteria for use of this drug 
have been met. 
 
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 Opdivo treatments have been met. Therefore, we decided that the Plan has 
to pre-approve Opdivo (nivolumab) treatments.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found you have 
asthma. The medical records are of telehealth visits, and there is no data on oxygenation. You are using oxygen 
at home, but oxygen need is not established in the records. There is no indication as to why a portable oxygen 
concentrator is required, rather than standard portable tanks. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (34713) provided July 19, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the billed number of units exceed the allowed amount. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 34713 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical 
services (34713) provided July 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (77012, 99153) provided September 7, 
2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the codes billed cannot be paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 77012 and 99153 are not supported in the medical record. Specifically, there is a 
bundled relationship between codes 49406 and 77012. Per the National Physician Fee Schedule CPT 99153 has 
a PC/TC indicator of 3 and is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not 
have to pay for radiology services (77012, 99153) provided September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99379) provided August 1, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is 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. 
 
We find that CPT code 99379 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule this service has a status of "B" and is bundled with another service. Based on this information, we 
decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided 
that the Plan does not have to pay for physician services (99379) provided August 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services provided to the enrollee on April 6, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the denied codes not supported in the medical record. Specifically, as the enrollee was inpatient at 
the time of services, it is not appropriate to report these services separately. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for neurology services provided to the enrollee on April 6, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an emergency room (ER) visit provided from August 
17, 2021, to August 19, 2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you were taken to the hospital after 
collapsing and found unconscious. You also say this bill should be paid in full. The Plan denied your request. 
The Plan says that you have been charged the correct cost sharing amount. 
 
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. The Plan did not provide medical records to show if you were admitted to the 
hospital. Without the medical records we are unable to determine if the cost share applied is correct. Therefore, 
we decided that the Plan has to waive the copayment for an emergency room (ER) visit provided from August 
17, 2021, to August 19, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from January 1, 2021, to January 28, 2021. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that after a fall the facility waited two 
days before transporting the enrollee to the emergency room. You also say that because of the fall that 
happened during his stay he required additional rehab, and you should not be responsible for the additional 
charges. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 enrollees contract with the Plan clearly says that enrollees 
must pay a $0 copayment for days 1-20 for an in-network skilled nursing stay. The Plan contract also says there 
is a $178 copayment for days 21-100. The enrollee is not being charged for the first 20 days he was in the SNF, from December 28, 2020, to January 
16, 2021. The enrollee is being asked to pay a total of $1,958, which is $178 a day for days 21-31 of a SNF 
stay from January 17, 2021, to January 28, 2021 ($178 copayment x 11 days = $1,958). A SNF stay falls within 
the Skilled Nursing Facility (SNF) Care benefit category. This means that the enrollee has been asked to pay 
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a skilled nursing facility (SNF) stay provided from January 1, 2021, to January 28, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 
27, 2021. 
 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 December 27, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no requirement for weaning from mechanical ventilation. 
 
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 the enrollee was admitted with status epilepticus from a LTACH where she was 
being treated for osteomyelitis. The record indicates that the enrollee continues to have a dense metabolic 
encephalopathy and requires ongoing acute care services. The enrollee continues to receive acute care services 
and these have not been denied. The medical record does not indicate that the enrollee requires services that she 
is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied. 
 
 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 admission to a long term acute care hospital (LTACH).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observation services 
provided from December 27, 2021, to December 28, 2021. You also asked the Plan to waive the copayment for 
an electrocardiogram (ECG) provided on December 27, 2021. 
 
You asked the Plan to waive the copayments for observation services and an ECG. You say that you sat with 
your mom in the waiting room the entire time when you were told she may be having a heart attack. You also 
say that if the insurance is charged for a room, it should be denied. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 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 $200 
copayment for outpatient hospital observation services. The Plan contract also says that enrollees must pay a 
$10 copayment for diagnostic testing, including ECGs. 
 
The enrollee has been asked to pay a $200 copayment for observation services. Observation services fall within 
the Outpatient Hospital Observation benefit category. The enrollee has also been asked to pay the allowed 
amount of $8.21, which is less than the $10 copayment for an ECG. An ECG 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 copayments for outpatient hospital observation services provided from December 27, 2021, to December 
28, 2021. You also asked the Plan to waive the copayment for an electrocardiogram (ECG) provided on 
December 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
27, 2021. 
 
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 December 27, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on July 22, 
2021, to July 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the SNF services. You say that this claim is only for outpatient therapies for a 
custodial resident. The Plan denied your request. The Plan says you did not get prior authorization in order to 
provide these services.  The Plan says that out-of-network care requires prior authorization. 
 
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. 
 Your facility is not a network provider with the Plan. 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. This authorization 
requirement applies to both inpatient and outpatient services. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) services provided on July 22, 2021, to July 30, 2021, by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on December 19, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 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 imaging services provided to the enrollee on December 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (29823) provided October 28, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 29823 is not supported in the medical record. Specifically, the operative report did not 
include documentation to meet the guidelines of a surgical shoulder arthroscopy, with extensive debridement.  
 
 
 
 Based on this information, we decided that Medicare rules for coverage of the surgical services have not been 
met. Therefore, we decided that the Plan does not have to pay for surgical services (29823) provided October 
28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided March 10, 
2021. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the records do not support the item billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case.  The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided 
March 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 20, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service should not be unbundled. 
 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 72131 
is a column II code to column I code 72132. 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 imaging services provided to the enrollee on November 20, 2021.