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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is not back to baseline and his walking 
ability has been affected. You say that you want him monitored so that the SNF staff can help rebuild strength. 
The Plan denied your request. The Plan says the records show the enrollee's condition does not meet the 
requirements for coverage of skilled nursing facility services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has a past medical history of dementia, diabetes and hyperlipidemia who 
presented to the acute hospital on September 20, 2022, with confusion and agitation. The enrollee was treated 
in the hospital with antibiotics for a urinary infection and medication management for dementia and condition 
has stabilized. The enrollee is weak and deconditioned and is working with physical and occupational therapy. 
Currently the enrollee is walking 150 feet with a wheeled walker with stand-by to contact guard assistance and 
is stand-by to minimum assist for transfers and activities of daily living. The enrollee does not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. Our reviewer also found the enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opzelura. 
 
You asked the Plan to pre-approve Opzelura. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Opzelura.  
 
Benefits for Opzelura 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA Next Generation Sequencing (NGS) test provided 
on May 19, 2022. 
 
You asked the Plan to pay for PrismRA testing. You say that this test is only performed by your lab and was 
ordered by the patient's doctor to inform the patient's treatment. The Plan denied your request. The Plan says 
this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for any NGS testing to be covered, the 
test must have FDA approval or clearance.  
 
We looked at the file and Medicare rules. The PrismRA test does not currently have FDA approval or 
clearance. Based on this information, we decided that Medicare rules for coverage of PrismRA testing have not 
been met. Therefore, we decided that the Plan does not have to pay for PrismRA Next Generation Sequencing 
(NGS) test provided on May 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the colon, also 
known as a virtual colonoscopy. 
 
You asked the Plan to pre-approve the virtual colonoscopy. You say that you need this in order to determine 
the cause of your intestinal bleeding. You would prefer to have this rather than a standard colonoscopy. The 
Plan denied your request. The Plan says an optical colonoscopy is the most appropriate treatment in this case. 
There is no medical reason that this cannot be performed. 
 
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 virtual colonoscopy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee requires colonic imaging due to rectal 
bleeding. The record provided does not document a sufficient medical rationale why a standard colonoscopy 
cannot be performed. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the virtual colonoscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the colon, also known as a virtual 
colonoscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (77523). 
 
You asked the Plan to pre-approve Proton Beam Radiation Therapy. You say that you do not agree with the 
denial and are requesting reconsideration. The Plan denied your request. The Plan says the request does not 
meet the Medicare or health Plan coverage criteria. 
 
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 Proton Beam Radiation Therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found for this enrollee, a dose comparison is provided with a handwritten note 
describing the intent to deliver curative intent treatment and to minimize dose to the optic nerves and chiasm in 
the spirit of ALARA [as low as reasonably achievable}. Yet the dose delivered to optic chiasm and optic 
nerves is well below accepted tolerances of 54-56 Gy maximum dose) with max doses from the non-proton 
plan of 22 Gy (chiasm) and 36 Gy (optic nerves). The handwritten note describes the concern about needed to 
retreat the enrollee at a future date, which is not a commonly accepted justification for proton therapy from any 
consensus guidelines or other source. The enrollee is receiving definitive intent radiotherapy and the non-
proton plan does not appear to exceed, or approximate, any accepted dosimetric constraints. Certainly, in the 
setting of reirradiation, were that ever need to be considered for this enrollee, proton therapy would potentially 
provide a plausible benefit (though with the need to justify that dosimetrically). But in the upfront setting, with 
what appears to be a safe and effective non-proton-based plan, the need for proton therapy is not justified. The 
case records provide no clinical history and no plausible justification of need of proton therapy. Proton therapy 
is not an accepted standard of care for routine practice for skin cancers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Proton Beam Radiation Therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Proton Beam Radiation Therapy (77523).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the head without contrast provided on February 12, 2022, billed with code 70450-XE. 
 
You asked the Plan to pay for the CT interpretation as billed. You say that this is billed correctly with a 
modifier to bypass the edit. The Plan denied your request. The Plan says the same physician billed and was 
paid for code 70460 on a separate claim. No modifier is allowed to bypass this edit pair. 
 
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 70460 with a modifier indicator of 0.  The column II code is therefore not payable. 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 interpretation of the computed 
tomography (CT) scan of the head without contrast provided on February 12, 2022, billed with code 70450-XE.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a specialist office visit and injection 
provided on March 15, 2022. 
 
You asked the Plan to waive the cost share for a specialist office visit and injection. You say that you received 
an approval letter for the injection that stated the service would be covered and you would not receive a bill. 
You say that no one informed you that there would be additional cost share for the injection. 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 a $50 
copayment for each Medicare-covered Specialist visit and 20% coinsurance for Part B drugs, including 
chemotherapy drugs.  
 
  You have been asked to pay a total of $2,087.74. This total includes a $50 copayment for a specialist office 
visit and $2,037.74, which is 20% of the allowed amount for an injection ($10,188.72 allowed x 20% = 
$2037.74). A specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office 
Visit, benefit category. An injection falls within the Medicare Part B Prescription Drugs 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 a specialist office visit and injection provided on March 15, 
2022.  
 
Your complaint about not being informed of the additional cost share for the procedure is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra intravenous (IV). 
 
You asked the Plan to pre-approve Actemra IV. 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 must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Actemra IV. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's specific clinical situation. The Medicare approved 
drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. The elements of the coverage criteria are not satisfied. 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 of Actemra IV have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Actemra intravenous (IV).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that this provider works with your specific 
condition. The Plan denied your request. The Plan says the services are available from network providers. 
 
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. The file shows that you have a benign 
lesion on your tongue that has no evidence of malignancy. 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 office 
visit 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 an explant of the old implantable loop recorder (ILR) 
and placement of a new ILR. 
 
You asked the Plan to pre-approve an explant of the old ILR and placement of a new ILR. 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 certain cardiac event monitors are covered 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 explant of the old ILR and 
placement of a new ILR. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the medical records do not show that the requirements for coverage are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an explant of the old ILR and placement of a new ILR have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an explant of the old implantable loop 
recorder (ILR) and placement of a new ILR.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on April 5, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you do not believe you should pay 
the 20% coinsurance for these charges because they were not disclosed to you by the Plan. 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 Medicare-covered Part B Chemotherapy drugs and other Part B drugs.  
 
 
  You have been asked to pay $61.90, which is 20% of the allowed amount for an injection ($309.50 allowed 
amount x 20% = $61.90). An injection falls within the Medicare Part B Prescription Drugs 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 an injection provided on April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on May 28, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that the provider did not do a good 
job on your wound and needed extra care later. This is why you want this copayment overturned. The Plan 
denied your request. The Plan says the copayment that was applied was 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 $30 
copayment for urgently needed services.  
 
You have been asked to pay a $30 copayment for an urgent care visit. An urgent care visit falls within the 
urgently needed 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 an urgent 
care visit provided on May 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from October 9, 
2021, to October 14, 2021. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you need help paying this bill. 
The Plan denied your request. The Plan says you were charged this cost sharing 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 $295 
copayment per day, for days 1 to 5 for inpatient hospital care.  
 
You have been asked to pay a $1,475 copayment for an inpatient stay ($295 per day x 5 days = $1,475). An 
inpatient stay falls within the Inpatient Hospital 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 an inpatient stay provided from October 9, 2021, to October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #18 (D2740) and core build up on tooth 
#18 (D2950) provided on June 3, 2022. 
 
You asked the Plan to pay for a crown and core build up. You say that you would like these services to be 
approved. The Plan denied your request. The Plan says a crown (D2740) and core build up (D2950) 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 pay for a crown 
on tooth #18 (D2740) and core build up on tooth #18 (D2950) provided on June 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on April 12, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you do not believe you should pay 
the 20% coinsurance for these charges because they were not disclosed to you by the Plan. 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 Medicare-covered Part B Chemotherapy drugs and other Part B drugs.  
 
 
  You have been asked to pay $61.90, which is 20% of the allowed amount for an injection ($309.50 allowed 
amount x 20% = $61.90). An injection falls within the Medicare Part B Prescription Drugs 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 an injection provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for knee injections provided on March 29, 
2022. 
 
You asked the Plan to waive the coinsurance for knee injections. You say that you did not know there would be 
a coinsurance for this service. The Plan denied your request. The Plan says you were charged this cost sharing 
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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug is $295.50 resulting in a 
$59.10 coinsurance ($295.50 x 20% = $59.10). 
 
You have been asked to pay a $59.10 coinsurance for knee injections. Knee injections falls within the Medicare 
Part B Prescription Drugs 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 knee 
injections provided on March 29, 2022.