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

 
We decided that the Plan has to pre-approve Yervoy (J9228) at a lowered dosage of 60 units x4 doses for a 
total of 240 units for 24 weeks of therapy. 
 
You asked the Plan to pre-approve Yervoy. You say that continuation of Ipilimumab would be a medical 
necessity based on the regimen you have chosen. You also say since the enrollee had previously progressed on 
Pembrolizumab, you elected to go with a regiment that provides ongoing deliver of Ipilimumab, albeit at a low 
dose, to overcome the resistance. The Plan denied your request. The Plan says that there is no supporting 
documentation in the approved compendia or the literature to support the lowered dose of Yervoy in 
combination with Opdivo. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 Yervoy. Our reviewer says that Yervoy 
(J9228) at a lowered dosage of 60 units x4 doses for a total of 240 units for 24 weeks of therapy is considered 
medically reasonable and necessary in this case. Our physician reviewer found the initial partial response and 
low dose in maintenance setting has been documented. Our reviewer also found that the documentation 
supports that Yervoy is safe and effective 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 Yervoy have been met. Therefore, we decided that the Plan has to pre-approve 
Yervoy (J9228) at a lowered dosage of 60 units x4 doses for a total of 240 units for 24 weeks of therapy.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 10, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by a chiropractor on April 21, 2022. 
 
You asked the Plan to pay for the services provided. You say that the services you received were not 
chiropractic services. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The file shows that you received therapeutic exercises (97110), vertebral decompression (S9090), and electrical 
stimulation (G0283) services. These services were provided by a chiropractor. When these services are 
provided by a chiropractor, they are not covered by Medicare or your plan. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the services provided by a chiropractor on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service September 
20, 2022. 
 
You asked the Plan to pay for the billed services. You say that anesthesia records were provided. The Plan 
denied your request. The Plan says the billed service cannot be verified. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status. 
 We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not show that 
the sedation services required an independent trained observver. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99152 billed for date of service September 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
September 9, 2022, to September 11, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you cannot afforde a $900 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $300 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $300 copayment per day for days 1-5 for inpatient hospital care. The total 
amount you are being asked to pay is $900 ($300 x 3 days = $900). This item/service 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 inpatient hospital care 
provided on September 9, 2022, to September 11, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for procedure code J3490 billed for date of service October 4, 2022. 
 
You asked the Plan to pay for the billed services. You say that the drug was used as part of the enrollee's 
treatment. The Plan denied your request. The Plan says that code J3490 is included in the payment for 
procedure 27096. 
 
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 J3490 is unclassified drugs. We find that CPT code J3490 
is supported in the medical record. The billed code was submitted with a national drug code that coincides with 
the drug documented in the medical records. Code J3490 is not an evaluation and management service. Drugs 
are separately payable. The Plan has not provided a Medicare rule that would indicate the drug should be 
included in the global surgery package. Based on this information, we decided that Medicare rules for coverage 
of the billed services have been met. Therefore, we decided that the Plan has to pay for procedure code J3490 
billed for date of service October 4, 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 pre-approve out-of-network (OON) tertiary care services. 
 You asked the Plan to pre-approve the OON tertiary care services. You say that the requested OON provider is 
a better fit for the enrollee's medical conditions. The Plan denied your request. The Plan says the services 
needed can be provided at their preferred tertiary care center. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 OON tertiary care services. Our 
reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the 
enrollee has a thoracic intramedullary mass. The Plan's denial is medically justified on the basis that it is 
offering adequate care to the meet the enrollee's medical needs through referral to an in-network tertiary level 
of care provider. There is nothing unique about the enrollee's condition that would make it medically necessary 
to see the requested OON provider. The Plan has shown that they have in-network tertiary care providers who 
meet the Standards of Care required for treatment of the enrollee's condition. 
 
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 OON tertiary care services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve out-of-network (OON) tertiary care services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
clinical value in spinal fusion surgery has not been demonstrated. 
 
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 is being treated for spondylolisthesis of the lumbosacral region. There is no 
specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is 
a lack of large volume, long-term peer-reviewed studies to support the use of bone marrow aspirate for this 
enrollees medical condition. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested bone marrow aspirate 
during the approved lumbar surgery, 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 30, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says an incorrect place 
of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on August 30, 2022.
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 a skilled nursing facility will not provide 
adequate physician, nursing, and therapy coverage and care for the enrollee's current health disposition. You 
say that the enrollee is not a candidate at this time for an acute rehab and has too many medical complications 
for a lower level of care. The Plan denied your request. The Plan says criteria for admission to the LTACH 
have not been met. 
 
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 there is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in 
transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care needs. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive hearing test provided on 
August 31, 2022. 
 
You asked the Plan to waive the copayment for a comprehensive hearing test. You say that you were told that 
you would only have to pay $20, not $40. The Plan denied your request. The Plan says this cost sharing was 
charged 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 
copayment for hearing services, including a diagnostic hearing exam. 
 
You have been asked to pay a $20 copayment for a comprehensive hearing test. This item/service falls within 
the hearing services, including a diagnostic hearing exam 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. The Plan confirmed that you saw two different 
providers on August 31, 2022. Therefore, we decided that the Plan does not have to waive the copayment for a 
comprehensive hearing test provided on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on May 17, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $475 
copayment for outpatient surgery.  
 
You have been asked to pay a $475 copayment for an outpatient surgery. However, you are only being asked to 
pay $321.70 which is less than the required amount. This item/service falls within the outpatient surgery 
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 outpatient surgery provided 
on May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 
08, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you are continue with the 
appeal until you receive reimbursement from the provider. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $5 
copayment for phyisican/practitioner services, including a specialist office visit. 
 
You have been asked to pay a $5 copayment for a specialist office visit. This item/service falls within the 
phyisican/practitioner services, including a specialist office visit 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 specialist office visit provided on August 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care visit provided on September 
29, 2022. 
 
You asked the Plan to waive the copayment for a primary care visit. You say that this was an annual wellness 
visit. The Plan denied your request. The Plan says this cost sharing was charged 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 $10 
copayment for in-network provider and professional services received in a primary care physicians office. 
 
You have been asked to pay a $10 copayment for a primary care visit. This item/service falls within the in-
network provider and professional services received in a primary care physicians office 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 primary care visit provided on September 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
June 20, 2022, to June 23, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you have a hospital bill 
for $8,544.80 that states care is not covered by Plan. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $260 
copayment each day for days 1-7 of a covered inpatient stay during a benefit period.  
 
 
  You have been asked to pay $260 copayment each day for three days, which is a total of $780 ($260 x 3 = 
$780) for inpatient hospital services. This item/service falls within the days 1-7 of a covered inpatient stay 
during a benefit period 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 inpatient 
hospital services provided from June 20, 2022, to June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a FreeStyle Libre 14-day sensor kit. 
 
You asked the Plan to pay for a FreeStyle Libre 14-day sensor kit. The Plan denied your request. The Plan says 
the information provided did not meet the requirements for covering this product. The Plan also says order for 
this product to be covered, the enrollee must (1) be using 3 or more insulin shots per day or be on an insulin 
pump; and (2) require frequent changes to their insulin dosing. 
 
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 
FreeStyle Libre 14-day sensor kit have not been met. Therefore, we decided that the Plan does not have to pay 
for a FreeStyle Libre 14-day sensor kit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Incruse. 
 
You asked the Plan to pre-approve Incruse. You say that the enrollee has tried several inhalers and found 
Incruse is the only one effective in managing her disease. The Plan denied your request. The Plan says Incruse 
is a self-administered drug and does not fall under Part B coverage. The Plan says that they do not administer 
pharmacy benefits for the enrollee. 
 
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 Incruse.  
 Benefits for Incruse may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.