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

 
We decided that the Plan does not have to pre-approve Pembrolizumab, Ondansetron, Darbepoetin, and 
Zoledronic Acid (J0881, J2405, J9271). 
 
You asked the Plan to pre-approve the Pembrolizumab, Ondansetron, Darbepoetin, and Zoledronic Acid. You 
say that the requested chemotherapy is medically necessary. The Plan denied your request. The Plan says 
coverage criteria has not been met. 
 
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 Pembrolizumab, Ondansetron, 
Darbepoetin, and Zoledronic Acid. Our reviewer says that the requested chemotherapy regimen is not 
medically necessary. Our physician reviewer found the record shows prior progression of disease on 
Pembrolizumab and Nivolumab. This regimen is not supported in the medical literature. 
 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 Pembrolizumab, Ondansetron, Darbepoetin, and Zoledronic Acid have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Pembrolizumab, Ondansetron, 
Darbepoetin, and Zoledronic Acid (J0881, J2405, J9271).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 17, 
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 these procedures require modifier 26. 
 
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 the denied codes is: 
 
CPT 88341: 
 
Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain 
procedure (List separately in addition to code for primary procedure) 
 
 
 CPT 88342: 
 
Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure 
 
CPT 88360: 
 
Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), 
quantitative or semiquantitative, per specimen, each single antibody stain procedure; manual 
 
CPT 88381: 
 
Microdissection (ie, sample preparation of microscopically identified target); manual 
 
We asked our coder 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 reviewer found that per the Correct Coding Initiative 
(CCI) edits, these denied codes require the use of modifier 26. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 9, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services were not urgent or emergent. 
 
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 laboratory services provided on February 9, 2022, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation will not be covered for certain 
circumstances. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gelsyn-3. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no literature evidence to support 
the efficacy of another viscosupplement working when the first injection failed to provide significant pain 
relief. Therefore, the request is deemed 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit/evaluation provided on September 28, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit/evaluation. You say that the services should be covered as you 
disagree with the denial and the services are medically necessary. The Plan denied your request. The Plan says 
the services denied correctly as 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 an office visit/evaluation provided on September 
28, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a radiologic examination of the chest 
provided on February 18, 2022. 
 
You asked the Plan to waive the copayment for a radiologic examination of the chest. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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 $50 
copayment for Outpatient Hospital Services-Basic Radiological Services.  
 
 
 
 
 
 
 You have been asked to pay a $50 copayment for a radiologic examination of the chest. The radiologic 
examination of the chest falls within the Outpatient Hospital Services-Basic Radiological Services 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 a radiologic examination of the chest provided 
on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit and medical supplies provided 
on November 17, 2021. 
 
You asked the Plan to waive the cost share for an office visit and medical supplies. You say that the charge 
shouldn't be this much and would like it reduced. The Plan denied your request. The Plan says the cost share 
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 medical supplies and a $35 copayment for a specialist office visit.  
 You have been asked to pay $817.14 for an office visit and medical supplies. You were asked to pay $35 
copayment for an office visit and $782.14 which is 20% of the allowed amount for the medical supplies. The 
allowed amount is $4,085.69 (20% x $4,085.69 = $782.14). The medical supplies fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category.  The office 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 cost share for an office visit and medical supplies provided on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit (99213) provided on February 24, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that the hospital is in-network, so any service 
provided by the house provider should also be in-network. The Plan denied your request. The Plan says the 
services were provided out-of-network and were not approved in advance. 
 
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 the outpatient visit (99213) provided on February 
24, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyOwnSkin Dermistat, skin graft. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
a lack of clinical evidence demonstrating an impact on improved health outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee underwent excision of basal cell carcinoma of the skin on the right shin on 
June 14, 2022. The repair size was 3.5 x 3.5 cm. Hemostasis was achieved by cautery. The enrollee was to 
follow-up for skin graft. MyOwnSkin Dermistat utilizes a small sample of a patient's skin to make a gel that is 
applied to the wound. MyOwnSkin is not currently available for sale. The product has been submitted to the 
FDA for a BLA (Biologics License Application). FDA rules require that the product be withdrawn from the 
market during the application process. The available documentation does not support that MyOwnSkin 
Dermistat is medically reasonable and necessary 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve MyOwnSkin Dermistat, skin graft.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria 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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the LCD criteria 
requires 3 months of pain relief following an epidural steroid injection. This was not achieved and therefore, 
the request is deemed 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 18, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. 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 March 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says the services are not medical 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 therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent slow deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee has had prior therapy and the documentation 
does not reveal that the enrollee requires the unique skills of a professional therapist to safely and effectively 
provide treatment. The enrollee has had education in a home education program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve four physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections (64484, 64483). 
 
You asked the Plan to pre-approve the repeat epidural steroid injections. You say that the injections are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat Epidural Steroid Injections are covered the 
medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline using the same scale for at least three months following the first injection. 
 
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 repeat epidural steroid injections. 
Our reviewer says that the repeat injections are not medically necessary. Our physician reviewer found the 
record does not show sustained 50% pain relief from the previous injections. 
 
 
 
 
 
 
 
 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 repeat epidural steroid injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve repeat epidural steroid injections (64484, 64483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the foot orthotics. 
 
You asked the Plan to pre-approve the foot orthotics. You say that you would like this claim reprocessed for 
medical necessity. The Plan denied your request. The Plan says this equipment is only covered if the enrollee 
has a medically necessary brace. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for orthotics to be covered for people 
with diabetes, the criteria in the Medicare rules section must be met. 
 
We looked at the file and Medicare rules. In this case, the record does not contain evidence that a certifying 
physician, defined as an MD or DO, has documented the effects of the enrollees diabetes as required by the 
Medicare coverage criteria. Based on this information, we decided that Medicare rules for coverage of the foot orthotics have not been met. Therefore, we decided that the Plan does not have to pre-approve the foot 
orthotics.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 60 additional routine transport trips (A0120). 
 
You asked the Plan to pre-approve the additional routine transport trips. You say that the additional trips are 
medically necessary. The Plan denied your request. The Plan says this benefit has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 60 additional routine transport trips (A0120).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee was transitioned to Xarelto after being on an IV heparin drip. Prior to admission to the 
hospital, the enrollee was modified independent with mobility and performing his activities of daily living. He 
used a cane for assistance with ambulation. He lives at home with his family in a two-story home. Currently, 
the enrollee is independent with upper body dressing. He requires maximum assistance with lower body 
dressing and bathing. He is standby assistance for eating and grooming. He requires minimum assistance with 
transfers and bed mobility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
 
 
 
 
 
 
 
 
 
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion at L2-S1 for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered non-standard therapy, and would fall under the class of experimental 
and/or unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the computed tomography (CT) scan does corroborate congenital narrowing of the lumbar L2-3 and 
L3-4 levels with a noted congenital fusion at L4-5.  However, he is noted to be an every day smoker, which 
increases the risk for failed fusion(s). The documentation does not indicate any trial at smoking cessation prior 
to the requested surgery. There are limited large-scale, long-term references showing the safety and efficacy of 
the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
lumbar fusion at L2-S1, in this case, 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar fusion at L2-S1 for the enrollee.