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

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Botox is only covered for certain indications. 
 
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 Botox. Our reviewer says that the 
documentation does not support that Botox is medically reasonable or necessary. Our physician reviewer found 
the enrollee is scheduled for panniculectomy and incisional hernia repair following bariatric surgery with 
weight loss. The record provided does not document that the requested service is being used for an enumerated 
condition for which coverage is available. Therefore, the enrollee does not meet criteria for Botox. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient visit (99204) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient visit. You say that a consult for proton therapy should be 
covered. The Plan denied your request. The Plan says the services have been requested out-of-network. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an outpatient visit (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract removal surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve cataract removal surgery. You say that none of the in-network facilities 
have enough time or the correct equipment. The Plan denied your request. The Plan says the service has been 
requested out-of-network and there are in-network providers available. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
cataract removal surgery to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight additional physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the plan has no contractual obligation to cover additional physical therapy 
services that are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. The requested additional visits are not medically reasonable or necessary. Our physician reviewer 
found that the documentation does not indicate any significant improvement in function. The enrollee's 
objective measures have remained essentially the same. Therefore, the additional therapy and the skills of a 
physical therapist cannot be considered medically necessary. The patient can be educated in terms of a home 
exercise program and the use of a walker if further fall prevention is required with the approved sessions of 
physical therapy. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eight additional physical therapy visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on August 25, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says unauthorized, non-plan 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 in this case 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. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services provided on August 25, 2021 by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the power wheelchair you rented from 
April 1, 2022, to May 1, 2022. 
 
You asked the Plan to waive the coinsurance for the power wheelchair. You say that you were quoted different 
prices and do not understand how the billed amount was arrived at. The Plan denied your request. The Plan 
says you were not provided with misinformation and you were charged the correct coinsurance for this item. 
 
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 4% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 4% coinsurance for the power wheelchair. The power wheelchair falls within the 
durable medical equipment benefit category. The allowed amount for the rental of the wheelchair is $306.93 
per month and the allowed amount of the elevating leg rests you received is $17.15 per month.  Your 4% cost 
sharing of this allowed amount equals $12.93 per month ($306.03 + $17.15 = 323.18, $323.18 x 4% = $12.93). 
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 coinsurance for the power wheelchair you rented from April 1, 2022, to 
May 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the COVID-19 test you had in Mexico on April 1, 2022. 
 
You asked the Plan to pre-approve the COVID-19 test. You say that you needed this test to return home to the 
United States. The Plan denied your request. The Plan says COVID-19 testing for travel purposes is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover non-diagnostic COVID-
19 tests (such as those for public health surveillance or travel purposes). You received this testing not for a 
diagnostic purpose, but solely for travel. We looked at the file and Medicare rules. Based on this information, 
we decided that Medicare rules for coverage of the COVID-19 test have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the COVID-19 test you had in Mexico on April 1, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on February 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Unless a 
specific exception is met, laboratory claims should be reported with the date of service the specimen was 
collected. 
 
We find that the reported date of service of February 10, 2022, is supported in the medical record. Specifically, 
the records indicate that the sample was collected on February 10, 2022. Therefore, we decided that the Plan 
has to pay for the laboratory services provided on February 10, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta (20610, J3304). 
 
You asked the Plan to pre-approve the Zilretta. You say that Zilretta is medically necessary. The Plan denied 
your request. The Plan says a trial of Triamcinolone Acetonide is medically necessary 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 the Zilretta. Our reviewer says that 
Zilretta is not medically necessary. Our physician reviewer found the record shows no trial of the plan 
preferred drug or any reason it would be unsafe or ineffective 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 the Zilretta have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Zilretta (20610, J3304).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under the 
enrollees contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis (0037U) provided on 
October 8, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the targeted genomic sequence analysis. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
  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 a targeted genomic sequence analysis (0037U) 
provided on October 8, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a connective tissue graft on tooth #20 (D4275) and 
osseous tissue regeneration on tooth #20 (D4265). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says connective tissue graft (D4275) and osseous tissue 
regeneration (D4265) are 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
connective tissue graft on tooth #20 (D4275) and osseous tissue regeneration on tooth #20 (D4265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 20, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this service should be covered. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation, specialist visit, 
and x-ray provided from March 19, 2022, to May 5, 2022. 
 
You asked the Plan to waive the copayments for ambulance transportation, specialist visit, and x-ray. You say 
that you have received this bill four times and you are requesting the Plan take care of the copayment. The Plan 
denied your request. The Plan says the copayment applied is correct. 
 
  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 $300 
copayment for per one-way trip by ground or air ambulance, a $45 copayment for routine radiology per 
provider, per date of service, and a $35 copayment per outpatient specialist visit.  
 
You have been asked to pay $380 for ambulance transportation, specialist visit, and x-ray ($300 + $45 + $35 = 
$380). Ambulance transportation falls within Ambulance Services benefit category. The x-ray falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. A specialist visit 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 copayments for transportation and outpatient services provided from  
March 19, 2022, to May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
the provider was called in to see the patient.  That is why there is no authorization. The Plan denied your 
request. The Plan says unauthorized, non-plan 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 in this case 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. Therefore, we decided that the Plan does not have to pay for medical services provided on March 23, 2022, by an out-of-
network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31625 billed for date of service November 
12, 2021. 
 You asked the Plan to pay for procedure code 31625. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 31625 is bundled into 
payment for code 31641. 
 
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 31625 
is a column II code to column I code 31641. 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 31625 billed for date of service November 12, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from October 20, 
2021, to November 2, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, Medicare guidance says that diagnosis codes I42.9 and 
I25.10 are not present on the exempt from reporting list; however, the claim submitted has listed the POA as 
blank. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided 
from October 20, 2021, to November 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for the medical visit provided on March 1, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON medical visit. You say that because the patient was not seen in your 
office, you did not have any part in obtaining authorization. The Plan denied your request. The Plan says 
unauthorized, non-plan 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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical visit provided on March 1, 2022 by an 
out-of-network (OON) provider.
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. The Plan denied your request. The Plan says the drug is not 
indicated for the enrollee's condition. 
 
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 a diagnosis of leiomyosarcoma. The Food and Drug Administration 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.  No 
literature from Medicare approved cancer journals were submitted for review.  The elements of the coverage 
criteria are not satisfied.  Therefore, 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 have not been met. Therefore, we decided that the Plan does not have to pre-
approve pembrolizumab (Keytruda).