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

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on January 17, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the scan was part of your 5 year 
kidney cancer screening. 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 $180 
copayment for diagnostic radiology services in a provider's office or freestanding radiology center.  
 
You have been asked to pay a $180 copayment for the CT scan.  The CT scan 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 a computed tomography (CT) scan of the 
abdomen and pelvis provided on January 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo device. 
 
You asked the Plan to pre-approve a Barostim Neo device. You say that the requested Barostim Neo device is 
medically necessary. The Plan denied your request. The Plan says the requested Barostim Neo device 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 a Barostim Neo device. Our reviewer 
says that the requested Barostim Neo device is not medically necessary. Our physician reviewer found 
Baroreflex stimulation devices have been considered potential alternative treatments for resistant hypertension 
and heart failure. The Barostim Neo system is an electronic pulse generator implanted underneath the clavicle 
with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator delivers electrical 
impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the carotid arteries. In August 2019 
the FDA approved the system for use in patients with refractory heart failure who remain symptomatic despite 
treatment with guideline-directed medical therapy, are NYHA Class III, have an ejection fraction less than 
35%, and are not candidates for bi-ventricular pacing.  This was based on a clinical study demonstrating improvement in normal daily activities, distance walked, 
quality of life, and improved cardiac levels biomarker levels. There remains an absence of randomized, blinded 
clinical studies examining long-term clinical outcomes establishing the value of Barostim Neo in patient 
management. As a result, at this time the Barostim Neo system would not be considered medically reasonable 
and necessary in this enrollees clinical management. 
 
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 Barostim Neo device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dual-energy x-ray absorptiometry (DXA), bone density 
study (77085, G8417) provided on July 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a dual-energy x-ray absorptiometry (DXA), bone density study. You say that you 
were unaware that authorization was required for private services outside the United States coverage area. The 
Plan denied your request. The Plan says this care was not authorized, the services sought or obtained by the 
member was rendered by a provider who is not under contract with the Plan, and the services were not urgent. 
 
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 dual-energy x-ray absorptiometry (DXA), bone 
density study (77085, G8417) provided on July 14, 2021, by an out-of-network (OON) provider.
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 December 7, 2020, to December 23, 2020. 
 
You asked the Plan to waive the copayments for the PT services. You say that you were not charged any 
copayments at the times of service. 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 physical therapy visit.  
 
The file shows that you had 3 physical therapy visits from December 7, 2020, to December 23, 2020. You have 
been asked to pay a $40 copayment for each visit for the PT services, for a total of $120. 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 December 7, 2020, to December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says the enrollee's needs can be met in the current facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be somewhat unstable and with plans for possible colostomy 
procedure and should only require short-term additional acute care hospital services that can safely be 
administered at the current facility until more stable and appropriate for transfer. The patient does not require 
services at the LTACH that are not already available at the current facility. Transfer to LTACH is not 
medically necessary as it would not be clinically advantageous. Transfer may be considered when treatment 
has completed, and the patient is more stable.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing provided on November 
12, 2021. 
 
You asked the Plan to pay for the DecisionDx-Melanoma testing. You say that this is a Medicare-covered 
molecular diagnostic test. The Plan denied your request. The Plan says the National Comprehensive Cancer 
Network (NCCN) guidelines do not recommend this testing. As such, it is considered experimental. 
 
The Plan follows Medicare rules. Medicare rules say that molecular diagnostic testing, such as DecisionDx-
Melanoma testing, may be covered when the criteria from the Medicare rules section have been met. 
 
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 pay for the DecisionDx-Melanoma testing. Our 
reviewer says that the criteria for coverage of this test have not been met. Our physician reviewer found the 
enrollee is a male with a diagnosis of melanoma, nodular type, based on a shave biopsy performed on 10/25/21. 
The Breslow thickness was 2.6 mm. The pathologic stage was pT3a. The documentation does not demonstrate 
that the enrollee does not have metastatic disease, and that he has a presumed risk for a positive Sentinel 
Lymph Node Biopsy (SLNB) based on clinical, histological, or other information, which is greater than 5%. It 
has not been demonstrated that the information will influence management decisions regarding the 
appropriateness of adjuvant therapy and determining the appropriate level of follow-up, imaging, and referrals 
for this enrollee. As such, the criteria for this testing are not met. 
 
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 DecisionDx-Melanoma testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the DecisionDx-Melanoma testing provided on November 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan eye drops. 
 
You asked the Plan to pre-approve Rocklatan eye drops. You say that this drug is medically necessary to treat 
the patient's open-angle glaucoma. The Plan denied your request. The Plan says this drug is not covered under 
the patient's medical benefits. 
 
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 Rocklatan eye drops.  
 
Benefits for Rocklatan eye drops 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
August 5, 2021. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services 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 $90 
copayment for Emergency care.  
 
 
  You have been asked to pay a $90 copayment for an emergency room visit. 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 emergency room visit provided on August 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 Sensor. You say that the item is necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre 2 Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatment provided from October 22, 2021, 
through October 25, 2021. 
 
You asked the Plan to pay for acupuncture treatment. The Plan denied your request. The Plan says this provider 
is not supervised by any physician, PA, or NP/CNS. 
 
 The Plan must follow Medicare rules. The rules say that these treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture 
must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, there is no documentation that the acupuncture 
treatment at issue in this appeal meets the Medicare coverage criteria. The provided records do not document 
that the acupuncturist in this case was under the appropriate level of supervision of a physician, PA, or 
NP/CNS. Therefore, we decided that the Plan does not have to pay for acupuncture treatment provided from 
October 22, 2021, through October 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0013M) provided March 31, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this procedure is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has reaffirmed non-coverage for codes 
0012M and 0013M for CxBladder.  
 
We looked at the file and Medicare rules. This procedure is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (0013M) provided March 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane injections. 
 
You asked the Plan to pre-approve the Durolane injections. You say that you feel this treatment should be 
approved. The Plan denied your request. The Plan says step therapy rules have not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Durolane injections. Our reviewer 
says that the requested treatment is not medically necessary based on step therapy rules. Our physician 
reviewer found the enrollee is a 72-year-old female with pain related to osteoarthritis of the left knee, diagnosis 
confirmed with imaging studies. She has failed conservative treatment, Durolane injections have been 
requested. The health plan denied coverage for the Durolane as the plan requires a trial of drug(s) Euflexxa, 
Synvisc or Synvisc One before they will approve the requested drug. 
 
Based on the medical records provided the patient has not tried and failed the required drug(s).  There is no 
indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for 
the patient. 
 
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 Durolane injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Durolane injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
September 24, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered in full as the rendering provider is your primary care physician (PCP). The Plan denied your request. 
The Plan says the cost-sharing applied correctly based on the services 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 $40 
copayment for Physician/Practitioner services, including doctors office visits, specifically specialist visits. 
 
 
  You have been asked to pay a $40 copayment for a specialist office visit. The record indicates that the provider 
was not set to be your PCP until 10/1/21. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist 
office visit provided on September 24, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Tecentriq (J9022). 
 
You asked the Plan to pre-approve Tecentriq. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this use is not supported because of your disease progression. 
 
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 Tecentriq. Our reviewer says that the 
requested use of Tecentriq is supported. Our physician reviewer found Tecentriq is FDA-approved for use 
when the tumor has not grown more than 20% and does not meet RECIST (Response Evaluation Criteria in 
Solid Tumours) criteria for progression on the most recent computed tomography scan. The documentation 
support that the requested drug is safe and effective and otherwise 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 Tecentriq have been met. Therefore, we decided that the Plan has to pre-
approve Tecentriq (J9022).  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 47100 billed for date of service June 28, 
2021. 
 
You asked the Plan to pay for procedure code 47100. You say that you have provided medical records to 
support payment of this code. The Plan denied your request. The Plan says this code is not supported in the 
medical record, but the Plan has approved payment for code 48150. 
 
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 47100 is biopsy of liver, wedge. 
 
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 procedure code 47100. Our reviewer says that code 47100 is 
not supported by the medical record. Our reviewer found the operative report describes 2 firm nodules excised 
and sent for biopsy.  The documentation does not describe a Wedge biopsy was performed. Per NCCI Policy Manual "A pie shaped wedge of the liver is resected and sent for pathology" There is a more 
appropriate code to report for this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 47100 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 47100 billed for date of service June 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on October 4, 2021. 
 
You asked the Plan to pay for diagnostic radiology services. The Plan denied your request. The Plan says no 
authorization was obtained. 
 
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 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 diagnostic radiology services provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100) provided June 25, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is bundled with a primary service and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, this code has a status of "B" and is always bundled with another service. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided June 25, 
2021.