Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis bone growth stimulator to be rendered 
by the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested item. 
 
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 item at issue in this appeal.  We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis bone growth stimulator to be rendered by the out-of-network 
(OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered on September 24, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 97110 is not supported. 
 
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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the 
services were performed in the home setting and there is a more appropriate code for these services. 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 pay for the physical therapy services rendered on 
September 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (71045) provided on November 18, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 71045 
is a column II code to column I code 36558. 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 the services (71045) provided on November 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that this is medically necessary. The Plan denied your 
request. The Plan says that Opdivo is not being prescribed for a medically-accepted indication. 
 
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 Opdivo. Our reviewer says that Opdivo 
is not medically reasonable and necessary. Opdivo is not FDA-approved for your diagnosis with progression on 
prior PDL1 therapy. The use of Opdivo is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. Our physician reviewer found that your condition 
does not meet criteria for coverage of Opdivo. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the rental charges for the Trilogy 100 home ventilator for date 
of service May 12, 2021, billed with code E0466. 
 
You asked the Plan to waive the rental charges for the Trilogy 100 ventilator. You say that you have been 
overcharged for the Trilogy 100 device because it is being incorrectly billed with E0466 when you are not 
using the additional features that justify this higher cost code. You are prescribed this for use as bilevel positive airway pressure (BiPAP) which should be coded as E0471, which is a much lower monthly payment and would 
become yours after a certain number of payments. You state that due to code E0466 you are being charged a 
higher monthly payment and never obtain ownership of the device. You feel that you should only be required 
to pay what would be owed for the E0471 code since these are the only features of the device that you use. The 
Plan denied your request. The Plan says you have been assessed the correct cost sharing for this device based 
on your contract. 
 
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 durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the Trilogy 100 ventilator. The Trilogy 100 ventilator falls 
within the durable medical equipment and related 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 rental charges for the Trilogy 100 home ventilator for date of service May 12, 2021, billed with 
code E0466.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the rental charges for the Trilogy 100 home ventilator for date 
of service March 12, 2021, billed with code E0466. 
 
You asked the Plan to waive the rental charges for the Trilogy 100 ventilator. You say that you have been 
overcharged for the Trilogy 100 device because it is being incorrectly billed with E0466 when you are not 
using the additional features that justify this higher cost code.  You are prescribed this for use as bilevel positive airway pressure (BiPAP) which should be coded as E0471, 
which is a much lower monthly payment and would become yours after a certain number of payments. You 
state that due to code E0466 you are being charged a higher monthly payment and never obtain ownership of 
the device. You feel that you should only be required to pay what would be owed for the E0471 code since 
these are the only features of the device that you use. The Plan denied your request. The Plan says you have 
been assessed the correct cost sharing for this device based on your contract. 
 
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 durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the Trilogy 100 ventilator. The Trilogy 100 ventilator falls 
within the durable medical equipment and related 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 rental charges for the Trilogy 100 home ventilator for date of service March 12, 2021, billed with 
code E0466.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor. 
 
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of 
the therapeutic continuous glucose monitor have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the most appropriate level of 
care for this enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria 
for coverage. 
 
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 does not require services at the LTACH that are not already available at 
the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (denosumab) injections. 
 
You asked the Plan to pre-approve the Prolia injections. You say that the enrollee has a high risk of fracture 
and cannot tolerate alendronate. The Plan denied your request. The Plan says there is a lack of clear evidence of 
a failure of bisphosphonates or calcium/vitamin D supplementation. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Prolia injections. Our reviewer says 
that the requested Prolia treatment is not medically reasonable and necessary. Our physician reviewer found 
there is insufficient documentation of a failure of bisphosphonates or taking calcium/vitamin D 
supplementation. The review has determined that the documentation does not support that Prolia is medically 
reasonable or necessary for this patient. The documentation does not support that the Prolia is safe and 
effective for the patient. 
 
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 Prolia injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Prolia (denosumab) injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
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 Feraheme. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Infed and Venofer before they will approve the requested drug. The requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from, the plan's preferred step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Feraheme (Q0138).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services rendered on March 24, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that providers/suppliers have an obligation, under law, to 
conform to the requirements of the Medicare program. 
 
 
  We looked at the file and Medicare rules. There is no documentation to support that the services were 
performed for the date of service at issue. 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 pay for the 
telehealth services rendered on March 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Gammagard Liquid (J1569). 
 
You asked the Plan to pre-approve the Gammagard Liquid. You say that you would like reconsideration 
because the requested drug is medically necessary. The Plan denied your request. The Plan says payment for managed care plan members for the covered routine costs associated with a clinical 
trial is the responsibility of the original Medicare contractor. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the Gammagard Liquid as part of a clinical trial. The Plan does 
not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not 
have to pre-approve the Gammagard Liquid (J1569).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure (HF) system. 
 
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 services are not medically necessary. 
 
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 services are not medically necessary. Our physician reviewer found the enrollee has congestive heart 
failure. Although the CardioMEMs system has received Food and Drug Administration (FDA) approval, there 
is a lack of randomized, blinded clinical studies examining the long-term clinical outcomes. The services are 
therefore 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 a CardioMEMs Heart Failure (HF) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a miscellaneous hearing service (V5299). 
 
You asked the Plan to pre-approve a miscellaneous hearing service. You say that you purchased a hearing aid 
and the current warranty for the device expires on February 28, 2022. You also say you need an additional year 
of warranty for this device. The Plan denied your request. The Plan says hearing aid warranty is not covered by 
your benefit Plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan contract also 
says that a hearing aid warranty is not a Medicare covered benefit.  
 
We looked at the file and the Plan's rules. The records show you are requesting an additional year of warranty 
for your hearing aid device. Specifically, additional hearing aid warranty is not a covered benefit with your 
plan. Based on this information, we decided that the Plan's rules for coverage of a miscellaneous hearing 
service have not been met. Therefore, we decided that the Plan does not have to pre-approve a miscellaneous 
hearing service (V5299).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunohistochemistry rendered on August 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 88341 and 88342 are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 88341 (immunohistochemistry, each additional single 
antibody stain), 88342 (immunohistochemistry, initial single antibody stain), 88189 (flow cytometry), and 
88360 (morphometric analysis). Code 88341 is a column II code when billed with column I code 88360. Code 
88342 is a column II code when billed with column I code 88189.  The column II codes were not billed with an appropriate modifier to allow for separate payment. Therefore, we 
decided that the Plan does not have to pay for the immunohistochemistry rendered on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the rental charges for the Trilogy 100 home ventilator for date 
of service April 12, 2021, billed with code E0466. 
 
You asked the Plan to waive the rental charges for the Trilogy 100 home ventilator. You say that you have been 
overcharged for the Trilogy 100 device because it is being incorrectly billed with E0466 when you are not 
using the additional features that justify this higher cost code.  You are prescribed this for use as bilevel positive airway pressure (BiPAP) which should be coded as E0471, 
which is a much lower monthly payment and would become yours after a certain number of payments. You 
state that due to code E0466 you are being charged a higher monthly payment and never obtain ownership of 
the device. You feel that you should only be required to pay what would be owed for the E0471 code since 
these are the only features of the device that you use. The Plan denied your request. The Plan says you have 
been assessed the correct cost sharing for this device based on your contract. 
 
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 durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the Trilogy 100 ventilator. The Trilogy 100 ventilator falls 
within the durable medical equipment and related 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 rental charges for the Trilogy 100 home ventilator for date of service April 12, 2021, billed with 
code E0466.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound care to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the OON wound care. You say that you have seen several wound care 
specialists in the past year and a half, and your situation has not gotten better. The Plan denied your request. 
The Plan says the wound care services are available in the main 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 OON care. Therefore, we decided that the Plan does not have to pre-approve wound 
care to be provided by an out-of-network (OON) provider.