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

 
We decided that the Plan does not have to pre-approve Euflexxa injections. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the criteria have not been met.  
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when all 
of the conditions are met. 
 
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 Euflexxa. Our reviewer says that the 
Euflexxa injection is not medically necessary. Our physician reviewer found the provided documentation does 
not indicate that there is radiologic evidence of osteoarthritis of the knee. The reviewer also found no evidence 
the enrollee has failed at least three months of conservative therapy. Therefore, the reviewer found that the 
requested injection 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve a group three power wheelchair with multiple power options. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for the requested items. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair with multiple power 
options is only covered for certain indications. 
 
Review of the file shows that although there are three requested power options on this wheelchair (tilt, recline 
and elevating leg rests), there is not a medical need to control these power options through the joystick. The 
documentation shows that the enrollee is independent with feeding, toileting and modified independent with 
transfers. The enrollees 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. Therefore, 
we decided that the Plan does not have to pre-approve a group three power wheelchair with multiple power 
options.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided to the enrollee on January 12, 2022. 
 
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 that these codes are reimbursed to anesthesia providers only. 
 
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 services were provided by a certified registered nurse assistant/anesthesia 
assistant. The provider has not given a rationale as to why this provider is not appropriate for the services. 
Therefore, we decided that the Plan has to pay for anesthesia services provided to the enrollee on January 12, 
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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the outpatient therapy provided from November 11, 
2021, to January 13, 2022. 
 
You asked the Plan to waive the copayment for outpatient therapy. You say that you thought you were having 
physical therapy so the copayment should be $25. The Plan denied your request. The Plan says that the 
copayment applied is correct. 
 
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 submit documentation to confirm which type of outpatient 
therapy was received. This means that we cannot determine which copayment should be assessed. Therefore, 
we decided that the Plan has to waive the copayment for the outpatient therapy provided from November 11, 
2021, to January 13, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Psychotherapy on February 01, 2022. 
 
You asked the Plan to waive the copayment for psychotherapy. You say that you were told by the plan that the 
copayment was $30, and they came back and said it was $55. You paid the $30 copay and will not pay the 
difference. The Plan denied your request. The Plan says the cost-sharing amount the enrollee is being charged 
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 $55 
copayment for each out-of-network Medicare-covered individual or group therapy visit. Covered services 
include: Mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, 
clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-
qualified mental health care professional as allowed under applicable state laws.  
 
 
 You have been asked to pay a $55 copayment for psychotherapy. Psychotherapy falls within the Outpatient 
mental health care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for Psychotherapy on 
February 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87471, 87481, 87500, 87551, 87640, 87641, 
87651, 87653, 87798) provided on November 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim was billed with an invalid place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87471, 87481, 87500, 87551, 87640, 87641, 87651, 87653, 
87798) provided on November 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Infed and Venofer. 
 
 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 Injectafer. Our physician reviewer 
found that the enrollee has iron deficiency anemia due to malabsorption. The Plan requires a trial of Infed and 
Venofer before they will approve the requested drug, Injectafer. There is no indication that the enrollee has 
tried and failed the required drugs. There is no indication that the plan's required drugs would likely be less 
effective or likely have adverse effects for the 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the central venous tube insertion and 
chemotherapy services provided from November 11, 2021, to December 28, 2021 . 
 
You asked the Plan to waive the coinsurance for the central venous tube insertion and chemotherapy services. 
You say that you cannot afford these charges and they should be covered. The Plan denied your request. The 
Plan says the coinsurance 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 20% 
coinsurance for each Medicare-covered Part B drug from an in-network provider. Additionally, for the 
administration of that drug, you will pay the cost-sharing that applies to primary care provider services, 
specialist services, or outpatient hospital services. Your contract with the Plan clearly says that you must pay a 
$370 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient 
hospital, including but not limited to hospital or other facility charges and physician or surgical charges. 
 
 
You have been asked to pay a total of $1,917.38 for the central venous tube insertion and chemotherapy 
services.  
 
Date of Service Service Allowed Amount Coinsurance & 
Copayment 
Member Liability 
November 11, 2021 Tube Insertion $3320.61 $370 $370 
November 17, 2021- 
November 30 2021 
Infusions $164.75 $370 $164.75 
November 17, 2021- 
November 30 2021 
Chemotherapy 
Injections 
$2,296.65 20% $459.33 
December 1, 2021-
December 16, 2021 
Infusions $164.75 $370 $164.75 
December 1, 2021-
December 16, 2021 
Chemotherapy 
Injections 
$672.35 20% $134.47 
December 27, 2021-
December 28, 2021 
Infusions $164.75 $370 $164.75 
December 27, 2021-
December 28, 2021 
Chemotherapy 
Injections 
$2,296.65 20% $459.33 
TOTAL:    $1917. 38 
 
Chemotherapy injections fall within the Medicare Part B Prescription Drugs benefit category. The tube 
insertion and infusions fall within the Outpatient Surgery and Other Medical Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers 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 coinsurance for the central venous tube insertion and chemotherapy services provided from November 11, 
2021, to December 28, 2021 .
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99285) provided on 
September 1, 2020, with an out-of-network (OON) provider. 
 
You asked the Plan to pay for an emergency department visit. You say that you have confirmed that the 
providers type is correct for the emergency service billed. The Plan denied your request. The Plan says cpt code 
99285 was denied as evaluation and management codes are not covered for this specialty or provider type. 
Please bill with appropriate codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, there is insufficient 
information in the record. Based on this information, we decided that Medicare rules for coverage of an 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit (99285) provided on September 1, 2020, with an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (CPT code J3111). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says their physician reviewer has approved the drug under Part D of the members 
MAPD plan, through December 31, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Evenity (CPT code J3111). Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive airway 
pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary.  You have COPD and was found to have mild 
carbon dioxide (CO2) retention during a recent hospitalization for pneumonia. There are no pulmonary 
function studies to confirm the severity of the COPD, and no arterial blood gases (ABG) done while stable as 
an outpatient to document chronic CO2 retention. If there is chronic CO2 retention, you may benefit from 
BiPAP during sleep, which can provide the AVAPS mode of support. But Medicare does not cover a home ventilator when used as BiPAP. The denial is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Retacrit or Procrit 
 
 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 Aranesp. Our physician reviewer found 
that the enrollee has anemia. The Plan requires a trial of Procrit and Retacrit before they will approve the 
requested drug. The documentation does not support that Procrit or Retacrit would likely be less effective or 
would likely have adverse effects for the enrollee 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary Our physician reviewer found the enrolle has exudative age-related 
macular degeneration of the left eye with active choroidal neuvascularization. He has not tried and failed the 
Plan's required drug, Avastin. The records do not show that the required drug would be contraindicated or less 
effective; therefore, Lucentis is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lucentis.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from  
October 20, 2021, through October 21, 2021. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered 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 provided here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from October 20, 2021, through October 21, 2021.  
 Benefits for these items 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
27, 2021, to May 30, 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 inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 682 (RENAL FAILURE WITH MCC). We 
asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
review indicates that the documentation supported an admission for severe protein calorie malnutrition. 
Although the diagnosis of "AKI on CKD" was documented in the history and physical, supporting 
documentation for acute kidney injury was not found within the medical record. Although the patient had a 
creatinine 3.74 reported on admission, the attending provider noted "-Scr baseline around 2.8-3" in the history 
and physical. The review has determined that the records did not support the principal diagnosis code of N17.9. 
The records did not support DRG 682 (RENAL FAILURE WITH MCC).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from May 27, 2021, to May 30, 2021.