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

 
We decided that the Plan does not have to pre-approve Solifenacin, 10mg tablets. 
 
You asked the Plan to pre-approve Solifenacin, 10mg tablets. The Plan denied your request. The Plan says this 
medication falls under Part D 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 Solifenacin, 10mg tablets.  
 
Benefits for Solifenacin, 10mg tablets 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine eyewear provided on May 28, 2021. 
 
You asked the Plan to pay for eyewear. You say that your glasses could not be fixed so a replacement was 
ordered, and you were not informed that you would be charged for this. The Plan denied your request. The Plan says the denial of payment for this item is correct, because routine lenses and frames are only covered once 
every 2 years and you previously received glasses on September 24, 2020. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers routine eyewear once every 2 plan-years. 
 
We looked at the file and the Plan's rules. You previously received covered eyewear on September 24, 2020; 
therefore, the routine eyewear benefit was exhausted at the time this eyewear was purchased. Based on this 
information, we decided that the Plan's rules for coverage of eyewear have not been met. Therefore, we decided 
that the Plan does not have to pay for routine eyewear provided on May 28, 2021.  
 
Your complaint regarding not being told that you would be charged for this eyewear is considered to be a 
grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the 
Plan for more information about your grievance.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Minimally Invasive Lumbar Decompression (MILD) for 
the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this procedure has not been shown to improve health outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The MILD procedure 
is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Minimally Invasive Lumbar Decompression (MILD) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood oxygen testing rendered on October 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of T represents a code that is only 
paid if there are no other services payable under the physician fee schedule billed on the same date by the same 
provider. 
 
We looked at the file and Medicare rules. Billed procedure code 94761 (noninvasive ear or pulse oximetry for 
oxygen saturation; multiple determinations [eg, during exercise]) has a status indicator of T and was not billed 
without other services that were not payable under the physician fee schedule on the same date. Therefore, we 
decided that the Plan does not have to pay for the blood oxygen testing rendered on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on May 5, 2021.
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 provided on November 27, 2021, billed with code 70450. 
 You asked the Plan to pay for the CT scan interpretation. You say that this should be paid as the services were 
medically necessary. The Plan denied your request. The Plan says this was not billed with a clinically 
appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of the 
head provided on November 27, 2021, billed with code 70450.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 9, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says code 70450 is not separately payable from 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 9, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on October 12, 2021. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says the services are 
not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to 
pay for an eye refraction provided on October 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tildrakizumab. 
 
You asked the Plan to pre-approve tildrakizumab. The Plan denied your request. The Plan says the request for 
tildrakizumab remains denied based on lack of medical necessity for the medication. 
 
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 tildrakizumab. Our reviewer says that 
the elements of the coverage criteria are not satisfied, and the requested drug cannot be recommended. Our 
physician reviewer found that a test for tuberculosis was cancelled due to receipt of an inadequate specimen. 
The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tildrakizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve tildrakizumab.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 19, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on January 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided August 27, 2021, 
to September 8, 2021. 
 
You asked the Plan to pay for the acute inpatient level of care. You say that the enrollee was under traditional 
Medicare when they were admitted. You also say that the facility was not aware that the enrollee became 
enrolled in a different plan starting in September. The Plan denied your request. The Plan says the claim was 
processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan that covered the enrollee at the 
beginning of an inpatient stay is responsible for the entire stay. If there is a change in coverage during the stay, 
the new Plan is not responsible for inpatient hospital care until after the date of discharge.  
 
A different health plan was not the Plan of record at the time of the inpatient stay at issue in this appeal began. 
This means that the new plan is not responsible for coverage of inpatient hospital services until after this stay 
ended. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided 
August 27, 2021, to September 8, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a telehealth visit with an out-of-network physician (G2012) provided 
on July 30, 2021. 
 
You asked the Plan to pay for a telehealth visit with a physician. You say that the service at issue was a 
necessity for the enrollee's care. The Plan denied your request. The Plan says that rules for payment have not 
been met because the service at issue was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that PPO plans must provide reimbursement for all 
plan-covered medically necessary services received from non-contracted providers without prior authorization 
requirements. 
 
We looked at the file and Medicare rules. In this case, the service at issue was provided by an out-of-network 
provider. The Plan has not provided medical records on which to base a determination of medical necessity. It 
is the Plan's responsibility to substantiate its denial rationale. The Plan has not done so in this case. Based on 
this information, we decided that Medicare rules for coverage of a telehealth visit with a physician have been 
met. Therefore, we decided that the Plan has to pay for a telehealth visit with an out-of-network physician 
(G2012) provided on July 30, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested use is not supported. 
 
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 use of Keytruda is not supported. Our physician reviewer found based on the medical records 
provided, the guidelines of the National Comprehensive Cancer Network, and the Medicare-approved major 
drug compendia there is no documentation that the requested use of Keytruda is Food and Drug 
Administration-approved for the enrollees diagnosis. The use of Keytruda for the enrollees diagnosis does not 
meet Medicare criteria for safe, effective, and otherwise reasonable and necessary for this 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the dual-energy x-ray absorptiometry 
(DXA), bone density study (77080) provided on May 18, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $25 
copayment for basic radiological services provided at a specialists office, urgent care center, outpatient 
hospital, and freestanding radiological facility.  
 You have been asked to pay a $25 copayment for the radiological service provided at an outpatient hospital. 
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 dual-energy x-ray absorptiometry (DXA), bone density 
study (77080) provided on May 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36573 billed for date of service September 
27, 2021. 
 You asked the Plan to pay for procedure code 36573. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 36573 is bundled into payment for 36558. 
 
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 36573 
is a column II code to column I code 36558. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 36573 billed for date of service September 27, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from an inpatient acute rehab stay. 
The Plan denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care.  You were evaluated in the Emergency Department for syncope and were discharged home with home health 
care. There is ongoing weakness. Your medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There 
is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not 
meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no definitive evidence that the monitor, compared to 
conventional medical management and clinical monitoring, has been established as standard of care towards 
improved congestive heart failure (CHF) or cardiac outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. This CardioMEMS is 
being requested for management of CHF in this patient. The CardioMEMS device was approved by the FDA in 
2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery 
pressure in the management of patients with CHF. The clinical study on which FDA approval was based 
showed improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS 
system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat 
limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with 
the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the 
clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in this patients clinical management. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on June 29, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the out-of-network visit. You say that you were not aware this was an out-of-
network provider The Plan denied your request. The Plan says out-of-network services are covered only in 
certain limited circumstances. The services at issue were not urgent or emergent and could have been 
performed by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on June 29, 2021, 
by an out-of-network (OON) provider.