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

 
We decided that the Plan does not have to pre-approve Vumerity for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Vumerity for the enrollee.  
 
Benefits for this drug 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra eye drops. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Xiidra eye drops.  
 
 
  
 
Benefits for these services 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service January 31, 
2022. 
 You asked the Plan to pay for procedure code 71045. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 36556. 
 
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 71045 
is a column II code to column I code 36556. 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 71045 billed for date of service January 31, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint. 
 
You asked the Plan to pre-approve radiofrequency ablation to the SI joint. You say that radiofrequency ablation 
to the SI joint is medically necessary. The Plan denied your request. The Plan says the clinical value and 
effectiveness of radiofrequency ablation to the SI joint in the setting of sacroiliitis have not been demonstrated 
in the peer-reviewed literature 
 
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 radiofrequency ablation to the SI joint. 
Our reviewer says that the requested radiofrequency ablation to the SI joint is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that radiofrequency ablation of the lateral 
sacral branches is considered experimental/investigational because of the wide variation in efficacy in the peer-
reviewed literature. Therefore, the request is deemed 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 radiofrequency ablation to the SI joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the multianalyte assays with algorithmic analyses (0012M) 
provided November 12, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you believe that the evidence supporting the 
use of Cxbladder Detect as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says this service does not meet Medicare criteria of being medically reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. This test has not been evaluated by the MolDx Program's technical 
assessment process and LCD 35396 cites it as noncovered Based on this information, we decided that Medicare 
rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not 
have to pay for the multianalyte assays with algorithmic analyses (0012M) provided November 12, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the NeoTYPE Myeloid Disorders Profile provided on December 21, 
2021, billed with code 81455. 
 
You asked the Plan to pay for the NeoTYPE Myeloid Disorders Profile. You say that this was medically 
necessary testing that is covered by Medicare. The Plan denied your request. The Plan says that genetic testing 
procedures billed with code 81455 are not likely to impact therapeutic decision-making and is therefore 
considered noncovered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as 
TEST NAME are subject to the MolDX application, assessment, and approval process. Once this is complete, 
the test is assigned a reimbursement rate and unique test identifier.  
 
The definition of code 81455 is Targeted genomic sequence analysis panel, solid organ or hematolymphoid 
neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, 
CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, 
MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and 
copy number variants or rearrangements, if performed. 
 
We looked at the file and Medicare rules. The NeoTYPE Myeloid Disorders Profile has been reviewed by the 
MolDX contractor and was found to meet Medicare criteria and is covered. In addition, the profile examines 54 
genes meaning that the code 81455 would be appropriate. There is no Medicare rule for this jurisdiction which 
indicates that code 81455 is never covered. Based on this information, we decided that Medicare rules for 
coverage of the NeoTYPE Myeloid Disorders Profile have been met. Therefore, we decided that the Plan has to 
pay for the NeoTYPE Myeloid Disorders Profile provided on December 21, 2021, billed with code 81455.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
September 4, 2021, to September 5, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were never 
admitted as an inpatient and received no paperwork on your discharge. The Plan denied your request. The Plan 
says medical records received show the enrollee was held for observation and admitted after an emergency 
room visit. Therefore, the proper copayment 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 $300 
copayment Each time you are admitted to an acute care hospital.  
 
  You have been asked to pay a $300 copayment for the inpatient hospital stay. The inpatient hospital stay falls 
within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an inpatient hospital stay provided from September 4, 2021, to September 5, 2021.  
 
Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Vision Care services on February 21, 2022. 
 
You asked the Plan to waive the copayment for Vision Care services. You say that you feel the claim should 
have a specialist copayment of $45.00 applied and not the vision copayment of $50.00. The Plan denied your 
request. The Plan says the cost share applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for Vision Care services.  
 
You have been asked to pay a $50 copayment for Vision Care services. Vision Care 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 Vision Care services on 
February 21, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a psychotherapy office visit provided on 
January 14, 2022. 
 
You asked the Plan to waive the copayment for a psychotherapy office visit. You say that you never went to 
see any doctors this year.  You say that all your appointments are for April and May, and you don't need any 
crisis services. The Plan denied your request. The Plan says you have been charged the correct copayment 
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 $20 
copayment for Medicare-covered services provided by a state-licensed psychiatrist or doctor, clinical 
psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant or other 
Medicare-qualified mental health professional as allowed under applicable state laws.  
 
You have been asked to pay a $20 copayment for a psychotherapy office visit. The psychotherapy office visit 
falls within the Outpatient mental health 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 a psychotherapy office visit provided on January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Ottobock Kenevo microprocessor knee (L5848, 
L5845, L5856, L5828). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the arguments given in favor of the microprocessor knee are nearly verbatim those 
provided by the prosthetist/vendor to justify the knee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical 
purpose.  
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this request exceeds your needs and does not meet the criteria to be considered medically reasonable or 
necessary. The requested microprocessor knee has features such as intuitive use of a stationary indoor 
bicycle,  adjustments from a smartphone with the Cockpit app, and convenience features of charging without 
removing the foam cover. The physician documentation does not reveal that the patient requires a 
microprocessor knee over a K3 mechanical knee. The requested Kenevo knee has deluxe features which are not 
medically necessary for the patient.  
 
We looked at this physician's review, the file, and Medicare rules. The requested microprocessor knee has 
multiple deluxe features that would not be considered primarily medical in purpose. Based on this information, 
we decided that Medicare rules for coverage of the item have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Ottobock Kenevo microprocessor knee (L5848, L5845, L5856, L5828).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 12, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on November 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclosporine capsule 25mg 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this modified capsule is a self-administered drug that does not fall under Part B 
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 Cyclosporine capsule 25mg
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hip joint replacement surgery with an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the hip and joint replacement with an OON provider. You say that you are 
in severe pain and cannot put off another appointment. The Plan denied your request. The Plan says federal 
regulations don't allow for them to pay a provider who has elected to opt out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal are to be provided in a non-urgent, non-emergent situation by a provider 
who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pre-approve 
hip joint replacement surgery with an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on September 28, 
2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you received no notice that there 
was an outstanding bill. You say that this is a required ultrasound every two years, and it is not arbitrary. The 
Plan denied your request. The Plan says you have been charged the correct copayment 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 $110 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as radiology center or medical clinic). 
 
 
 
 You have been asked to pay $107.86 which is less than the standard $110 copayment for an ultrasound. An 
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 ultrasound provided on September 28, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a kidney transplant (50360, 50547). 
 
You asked the Plan to pre-approve a kidney transplant. You say that due to long wait times, the enrollee needs 
to be put on the transplant list early. The Plan denied your request. The Plan says that the enrollee is not 
currently a candidate for a transplant. 
 
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 a kidney transplant. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found a kidney transplant evaluation may be initiated when the eGFR (estimated glomerular filtration 
rate) reaches 20 or less. The creatinine value is not the standard criteria used for determination of when workup 
will begin. Starting the transplant workup allows the patient to accrue time sooner. This is standard of 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 a kidney transplant have been met. Therefore, we decided that the Plan has to 
pre-approve a kidney transplant (50360, 50547).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from January 5, 2022, to January 11, 2022. 
 
You asked the Plan to waive the copayments for the PT services. You say that you were informed by the 
provider that there would not be any copayments for the services. 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 $20 
copayment for each physical therapy visit.  
 
 
 You have been asked to pay a $20 copayment for each visit for the PT services, for a total of $40. 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 January 5, 2022, to January 11, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection(s), of a diagnostic or therapeutic substance, not 
including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, 
lumbar or sacral; with imaging guidance (62323) and the low osmolar contrast material, 200-299 mg/ml iodine 
concentration, per ml (Q9966) rendered by the out-of-network (OON) provider on June 4, 2021. 
 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 Point of Service benefit allows enrollees to access other 
services from non-network providers with a referral from their primary care physician.  
 
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. 
A referral was not provided by the enrollees primary care physician. 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 
injection(s), of a diagnostic or therapeutic substance, not including neurolytic substances, including needle or 
catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral; with imaging guidance (62323) 
and the low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml (Q9966) rendered by the 
out-of-network (OON) provider on June 4, 2021.