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

 
We decided that the Plan has to pre-approve doxorubicin hydrochloride (J9000), cyclophosphamide (J9070), 
and pembrolizumab (J9271). 
 
You asked the Plan to pre-approve doxorubicin hydrochloride, cyclophosphamide, and pembrolizumab. You 
say that the services are necessary. The Plan denied your request. The Plan says that based on the 
documentation provided, coverage criteria has not been met. 
 
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 doxorubicin hydrochloride, 
cyclophosphamide, and pembrolizumab. Our reviewer says that the services are medically necessary. Our 
physician reviewer found the enrollee had progression of disease on neoadjuvant chemotherapy and on surgery 
found to have a T2 tumor. Had she had this prior to surgery then the addition of pembrolizumab would have 
been indicated. She has an aggressive tumor that could be considered locally recurrent as well requiring the 
most aggressive treatment available. Studies in neoadjuvant setting show that this regimen is safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of doxorubicin hydrochloride, cyclophosphamide, and pembrolizumab have been 
met. Therefore, we decided that the Plan has to pre-approve doxorubicin hydrochloride (J9000), 
cyclophosphamide (J9070), and pembrolizumab (J9271).  
 
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: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 64308) provided to the enrollee on 
July 27, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
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 63048 is "Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of 
spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; 
each additional vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for primary 
procedure)." 
 
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 supported by the medical records. Our reviewer found that the enrollee was being treated for 
spondylosis with radiculopathy of the lumbar region. She underwent a posterior spinal fusion at L4/S1; 
posterior segmental instrumentation of the spine at L4 to S1 with Medtronic using navigation; posterior 
decompression with laminectomies and foraminotomies L5-S1; and posterior decompression with 
laminectomies and foraminotomies L4-5; use of allograft bone and DBM for posterolateral fusion at L4 to S1 
on 7/27/22. The procedure report cites that (during the procedure) a partial facetectomy and laminectomy of the 
L5-S1 level had to be performed. There was also a decompression performed at L4-5. Therefore, the records do 
support that a laminectomy represented by CPT 63048 was rendered in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 64308) provided to the enrollee on July 27, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 08, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that the billing should be part of 
preventative maintenance with no 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 $60 
copayment for a Medicare-covered ultrasound. 
 
You have been asked to pay a $60 copayment for an ultrasound. This item/service falls within the a Medicare-
covered ultrasound 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 ultrasound 
provided on June 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing care provided on January 17, 2022, to 
January 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing care. You say that you work with the hospital and should not require 
separate authorization. The Plan denied your request. The Plan says a referral/authorization was not obtained 
prior to services being rendered. 
 
  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 subsequent nursing care provided on January 17, 
2022, to January 27, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the breathing assistance device provided 
on January 26, 2022, to May 26, 2022. 
 
You asked the Plan to waive the coinsurance for the breathing assistance device. You say that you were 
informed you would no longer have to pay for the machine. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for the breathing assistance device. This item/service falls within 
the durable medical equipment (DME) 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 coinsurance for the breathing assistance device provided on January 26, 2022, to May 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on January 27, 2022, 
to January 29, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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 $360 
copayment per day for days 1 through 5 for covered hospital care. Includes inpatient acute, inpatient 
rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care 
starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. 
 
 
 
 
 You have been asked to pay a $360 copayment for inpatient hospital stay. 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 stay on January 27, 2022, to January 29, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the minimally invasive lumbar decompression (MILD) 
(0275T) procedure. 
 
You asked the Plan to pre-approve the MILD procedure. You say that the requested MILD procedure is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested MILD procedure. 
 
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 MILD procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MILD procedure is experimental, and more research is needed. 
 
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 MILD procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the minimally invasive lumbar decompression (MILD) (0275T) procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (90750) and administration (90471) 
provided on March 17, 2022. 
 
You asked the Plan to pay for the shingles vaccine and administration. You say that you were under the 
impression that the shingles vaccine and administration was a packaged two dose vaccine, and not a charge for 
each shot. The Plan denied your request. The Plan says this vaccination and administration are not covered 
under your Part B benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine 
and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine and administration. Therefore, we decided that the Plan does not have to pay for the shingles vaccine 
(90750) and administration (90471) provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) and the electrical stimulation 
(G0283) provided on June 30, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services at issue are not payable as they 
are not a covered benefit by the Plan or by Medicare. 
 
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 records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99204) and the electrical stimulation (G0283) provided 
on June 30, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-emergent ambulance provided on May 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a non-emergent ambulance. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says there was no preauthorization by a primary 
care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was 
not an emergency. Therefore, the decision is upheld. 
 
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 a non-emergent ambulance provided on May 19, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an esophagogastroduodenoscopy provided 
on June 20, 2022, to June 21, 2022. 
 
You asked the Plan to reduce the copayment for an esophagogastroduodenoscopy. You say that you thought 
this would be a $200 copay at the most. You think the $350 was too high, and that you must have been sent to 
the wrong surgical center. 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $350 copayment for an esophagogastroduodenoscopy. This item/service falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to reduce the copayment for an 
esophagogastroduodenoscopy provided on June 20, 2022, to June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care on June 04, 2022. 
 
You asked the Plan to waive the copayment for urgent care. You say that you want to appeal the amount being 
charged. 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 $50 
copayment for ach Medicare-covered urgent care facility visit. This copayment is not waived if you are 
admitted as an inpatient to the hospital within 24 hours for the same condition. Urgently needed services are 
provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate 
medical care. Urgently needed services may be furnished by network providers or by out-of-network providers 
when network providers are temporarily unavailable or inaccessible. 
 
 
 
 You have been asked to pay a $50 copayment for urgent care. This item/service 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 urgent care on June 04, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance provided on July 08, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for ambulance. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says prior authorization is required for non-emergency transportation. 
 
 
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 ambulance provided on July 08, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941 x 3) rendered 
by the out-of-network (OON) provider from June 22, 2022, through July 6, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the chiropractic manipulative treatment (98941 x 3) rendered by the out-of-
network (OON) provider from June 22, 2022, through July 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repair of nasal valve collapse with 
subcutaneous/submucosal lateral wall implant(s). 
 
You asked the Plan to pre-approve Repair of nasal valve collapse with subcutaneous/submucosal lateral wall 
implant(s). You say that the requested Repair of nasal valve collapse with subcutaneous/submucosal lateral 
wall implant(s) is medically necessary. The Plan denied your request. The Plan says the requested Repair of 
nasal valve collapse with subcutaneous/submucosal lateral wall implant(s) is 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 Repair of nasal valve collapse with 
subcutaneous/submucosal lateral wall implant(s). Our reviewer says that the requested Repair of nasal valve 
collapse with subcutaneous/submucosal lateral wall implant(s) is not medically necessary. Our physician 
reviewer found the record indicates that the enrollee has non-allergic rhinitis. There is insufficient literature to 
establish that the requested service is safer and more effective for the enrollee's clinical condition, as defined by 
Medicare rules, than other accepted therapies and does not exceed the enrollee's needs. 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. The requested service is not 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 Repair of nasal valve collapse with subcutaneous/submucosal lateral wall 
implant(s) have not been met. Therefore, we decided that the Plan does not have to pre-approve Repair of nasal 
valve collapse with subcutaneous/submucosal lateral wall implant(s).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided on April 20, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the services were 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan also says that the 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the office visit (99215) provided on April 20, 2022, by an out-of-network 
(OON) provider.