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

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necesary for the enrollee's 
condition. The Plan denied your request. The Plan says that the requested drug is not medically reasonable and 
necessary. 
 
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 Keytruda. Our reviewer says that the 
requested drug, Keytruda, is medically reasonable and necessary. Our physician reviewer found the enrollee is 
status post adjuvant chemotherapy with carboplatin/Alimta for stage III non-small cell lung cancer. They were 
initially treated with oral Kirsten rat sarcoma virus (KRAS) inhibitor and have experienced progression. In this 
case, there is support for the requested drug in the National Comprehensive Cancer Network compendia. Per 
Medicare compendium, this request 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0483) provided on July 14, 2021. 
 
You asked the Plan to pay for code G0483. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says 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 G0483 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not contain 
evidence that definitive testing on 22 or more drug classes was performed. Based on this information, we 
decided that Medicare rules for coverage of code G0483 have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing (G0483) provided on July 14, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on January 6, 2022. 
 
You asked the Plan to pay for the F1CDx panel. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. Since this panel includes that, the 
denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on January 6, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says no separate payment is made for these 
laboratory services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genetic testing services provided on December 15, 
2021. 
 
You asked the Plan to pre-approve the genetic testing services. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says these services are not 
covered. 
 
Medicare rules say that panels of tests that include the FANCC gene are non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the next generation sequence testing 
panel included testing for the FANCC gene. This means this entire panel is not covered. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the genetic testing services provided on 
December 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrodesis, great toe (28750) osteotomy, with or without 
lengthening, shortening or angular correction, metatarsal (28308) unlisted procedure, foot or toes (28899) 
provided May 4, 2021. 
 
You asked the Plan to pay for the surgical procedure. You say that you were not told that the doctor would be 
billed as out of network which is against the law. The Plan denied your request. The Plan says this claim was 
processed with the correct cost share applied per the Evidence of Coverage. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to Physician/Practitioner services, 
including doctor's office visits. This is the amount you have to pay out-of-pocket before the Plan will pay their 
share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost 
for most of your covered services.  
 
The item or service you asked the Plan to pay for falls within the benefit category Physician/Practitioner 
services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is $750 deductible which applies to Physician/Practitioner services, including doctor's office 
visits. This cost sharing is a contractual obligation that had not been met at the time the surgical procedure was 
received on May 4, 2021. Therefore, we decided that the Plan does not have to pay for arthrodesis, great toe (28750) osteotomy, with or without lengthening, shortening or angular correction, metatarsal (28308) unlisted 
procedure, foot or toes (28899) provided May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing related to end-stage renal disease (ESRD) 
provided on January 10, 2022. 
 
You asked the Plan to pay for the ESRD-related lab testing. You say that there is no contractual agreement that 
indicates that these codes are included in payment to the dialysis facility. The Plan denied your request. The 
Plan says Medicare rules prohibit separate payment for ESRD testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab testing related to end-stage renal disease (ESRD) provided on January 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 12-month oxygen concentrator rental. 
 
You asked the Plan to pre-approve a 12-month oxygen concentrator rental. 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 there is no further payment for oxygen equipment 
during the 5-year reasonable useful lifetime (RUL) of the equipment after 36 rental payments have been made. 
 
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 a 12-month oxygen concentrator rental. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
received an oxygen concentrator in January 2018 and has not had a replacement. She is not eligible for a 
replacement until January 2023. The review has determined that the enrollee does not meet the coverage 
criteria detailed in the LCA. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a 12-month oxygen concentrator rental have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a 12-month oxygen concentrator rental.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 26, 
2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this is too costly, and you should 
not have this copayment. The Plan denied your request. The Plan says the copayment 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 $45 
copayment for an in-network specialist's office.  
 
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the In-Network 
Specialist's 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 specialist visit 
provided on August 26, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says that the criteria for coverage have not been satisfied as this drug is not being 
prescribed for a supported medically-accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the 
requested drug is medically reasonable and necessary for the enrollee's condition. Our physician reviewer 
found the enrollee has been diagnosed with metastatic colon cancer. In this case, the requested use of Keytruda 
is FDA-approved for the enrollees diagnosis as Keytruda is approved for the treatment of unresectable or 
metastatic tumor mutational burden-high solid tumors (TMB-H; =10 mutations/megabase [mut/Mb]; as 
determined by an approved test) in adult and pediatric patients who have progressed following prior treatment 
and have no satisfactory alternative treatment options. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81295, 81298, 81317, 81407, and 
81408) provided on November 2, 2021. 
 
You asked the Plan to pay for codes 81295, 81298, 81317, 81407, and 81408. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered as 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, we have confirmed that code 81295 
and 81298 are column II codes to column I code 81432 with a modifier indicator of 0. The column II codes are 
therefore not payable.  
 
The rules also explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules 
section, are not covered. Codes 81317, 81407, and 81408 were requested solely for screening purposes. 
Medicare does not cover these tests solely for screening purposes. 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 laboratory 
services (81295, 81298, 81317, 81407, and 81408) provided on November 2, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the influenza immunization. 
 
You asked the Plan to waive the copayment for the influenza immunization. You say that no one told you that 
there would be cost sharing for this service. The Plan denied your request. The Plan says that the clinic that 
provided this shot is considered an urgent care clinic, so the copayment applied 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). The enrollees contract with the Plan says that enrollees pay $0 cost 
sharing for eligible Medicare-covered immunizations.  There is nothing in this section of the Evidence of 
Coverage that says that a separate copayment may apply based on the location where you receive the 
immunization.  It is unreasonable for a member to know that separate cost sharing would apply when the 
language of the immunization section of the contract explicitly states that there is no coinsurance, copayment, 
or deductible for members eligible for Medicare-covered immunizations. Therefore, we decided that the Plan 
has to waive the copayment for the influenza immunization.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the comprehensive eye exam (92014) 
provided February 4, 2022. 
 
You asked the Plan to waive the copayment for the vision services. You say that you received a bill for $50. 
You will not be seeing this doctor again by you would like the Plan to pick up the $50 copayment The Plan 
denied your request. The Plan says the claim has been reprocessed with the correct copayment applied per the 
Evidence of Coverage. 
 
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 $30 
copayment for out of network exams to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay $30 copayment for the vision services. The vision services falls within the Vision 
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 the comprehensive eye exam 
(92014) provided February 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdominal ultrasound provided on 
February 10, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you did not request the ultrasound 
and were not aware of any copayment. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $105 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay a $105 copayment for the ultrasound. The ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and 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 copayment for an abdominal ultrasound provided on February 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from June 17, 2021, to April 19, 2022. 
 
You asked the Plan to waive the copayments for the PT services. You say that you are on a fixed income and 
cannot afford the copayments. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $40 
copayment for each therapy visit.  
 
The file shows you had a total of 29 PT visits from June 17, 2021, to April 19, 2022. You have been asked to 
pay a $40 copayment for each visit for the PT services, for a total of $1,160 ($40 copayment x 29 visits = 
$1,160). The PT services fall within the Outpatient Rehabilitation 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 copayments for physical therapy (PT) services provided from June 17, 2021, to 
April 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator (AED) 
vest provided on October 14, 2021. 
 
You asked the Plan to waive the coinsurance for the AED vest. You say that you were informed that insurance 
would cover the costs. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 durable medical equipment (DME) items.  
 
You have been asked to pay $586.29, which is 20% of the allowed amount for the AED vest ($2,931.45 
allowed amount x 20% coinsurance = $586.29). The AED vest 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 an 
automatic external defibrillator (AED) vest provided on October 14, 2021.