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

 
We decided that the Plan does not have to pay for the transcatheter aortic valve replacement (TAVR) rendered 
on December 15, 2022, to December 27, 2022. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that it is mandatory to report a clinical trial number on 
claims for items/services provided in clinical trials/studies/registries, or under Coverage with Evidence 
Development (CED). 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required clinical 
trial number. 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 pay for the transcatheter aortic valve 
replacement (TAVR) rendered on December 15, 2022, to December 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601) provided May 31, 2023. 
 
You asked the Plan to pay for the CPAP device. You say that you are submitting an appeal with supporting 
documents. The Plan denied your request. The Plan says replacement of Durable Medical Equipment is not 
covered if replaced within five years. 
 The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment was purchase on April 26, 2022, and is less than 5 years old. This 
means that replacement of this equipment due to wear is not covered at this time. Therefore, we decided that 
the Plan does not have to pay for the continuous positive airway pressure (CPAP) device (E0601) provided 
May 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 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 Methotrexate tablet.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for multiple in-network chemotherapy 
injections provided on July 20, 2023, to August 17, 2023. 
 
You asked the Plan to waive the coinsurance for multiple in-network chemotherapy injections. You say that 
this cost is too high for you and it will cause a hardship. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for multiple in-network chemotherapy injections. This 
item/service falls within the Medicare Part B prescription drugs 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. The total you owe is $1,807.38. Therefore, we 
decided that the Plan does not have to waive the coinsurance for multiple in-network chemotherapy injections 
provided on July 20, 2023, to August 17, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra. 
 You asked the Plan to pre-approve Actemra. The Plan denied your request. The Plan says the enrollee has not 
tried the preferred drugs.  
 
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 Actemra. Our physician reviewer found 
that Actemra was requested to treat rheumatoid arthritis. The Plan requires a trial of drug Remicade, Inflectra, 
infliximab, or Simponi Aria before they will approve the requested drug. In this case, the enrollee has not tried 
and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs 
would likely be less effective and/or likely have adverse effects for the 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 Actemra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Actemra.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the traction equipment (E0849), provided on June 21, 2023. 
 
You asked the Plan to pay for the traction equipment. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication the item was needed or ordered in the clinical records submitted.. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the traction equipment (E0849), provided on June 21, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a psychiatric consultation with an out-of-network provider on May 19, 
2023. 
 
You asked the Plan to pay for a psychiatric consultation. You say that the enrollee was referred for urgent 
psychiatric treatment, as the enrollee was potentially dangerous to themself. The Plan denied your request. The 
Plan says that there is no authorization on file. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for a psychiatric 
consultation with an out-of-network provider on May 19, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services received on April 11, 2023. 
 
You asked the Plan to pay for podiatry services. You say that this service was urgent due to a bleeding callus 
on your large toe. The Plan denied your request. The Plan says that because the care you received on April 11, 
2023, is considered routine foot care, it is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
 
  Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of 
podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for podiatry 
services received on April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 26, 2023. 
 
You asked the Plan to pay for lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collagen dressing (A6021) and fiber gelling dressing 
(A6196), provided on June 20, 2023. 
 
You asked the Plan to pay for the collagen dressing and fiber gelling dressing. You say that the items should be 
covered. The Plan denied your request. The Plan says the appeal needs to be sent to the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has The Plan has 
informed the provider where the appeal needs to be sent.. As the secondary insurer, the Plan cannot be held 
responsible for the collagen dressing and fiber gelling dressing until the primary insurer has denied the claim 
for these services. Therefore, we decided that the Plan does not have to pay for the collagen dressing (A6021) 
and fiber gelling dressing (A6196), provided on June 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the positron emission tomography (PET) 
scan provided on July 21, 2023. 
 
You asked the Plan to waive the coinsurance for the positron emission tomography (PET) scan. You say that 
you say that you should not have to pay the billed amount. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% 
coinsurance for advanced imaging services. 
 
You have been asked to pay 30% coinsurance for the positron emission tomography (PET) scan. This 
item/service falls within the advanced imaging 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 coinsurance for the positron emission tomography (PET) scan provided on July 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet (UV) light therapy system (E0691) provided 
on April 25, 2023. 
 
You asked the Plan to pay for the UV light therapy system. You say that the item was medically necessary. The 
Plan denied your request. The Plan says the records submitted do not show a diagnosis of psoriasis. 
 
The Plan must follow Medicare rules. Medicare rules say that UV cabinets are covered for selected patients 
with generalized intractable psoriasis. Using appropriate consultation, the MAC should determine whether 
medical and other factors justify treatment at home rather than at alternative sites, e.g., outpatient department of 
a hospital.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the UV light therapy system have not been met. Specifically, there is no indication the enrollee has 
psoriasis in the clincal records submitted. Therefore, we decided that the Plan does not have to pay for the 
ultraviolet (UV) light therapy system (E0691) provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network antigen therapy visit 
provided on June 24, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network antigen therapy visit. You say that you have 
been doing these treatments for a long time and never had to pay this much before for each visit. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an in-network antigen therapy visit. This item/service falls 
within the Medicare Part B prescription drugs 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. The total you owe is $27.89 ($139 x 20% = $27.89). Therefore, we decided 
that the Plan does not have to waive the coinsurance for an in-network antigen therapy visit provided on June 
24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne Heme (81455) provided on July 3, 2023, by 
an out-of-network (OON) provider.   
You asked the Plan to pay for the genetic testing. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. This testing is also considered unproven as there is insufficient evidence in its efficacy. 
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 FoundationOne Heme (81455) provided on July 3, 2023, by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure is not medically necessary. The 
Plan says that medical studies have not proven this service is helpful for the treatment of the enrollee's health 
problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing only Modic changes 
without facet degenerative joint disease or stenosis. The cause of pain is not clear. 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carvedilol. 
 
You asked the Plan to pre-approve Carvedilol. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
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 Carvedilol.  Benefits for Carvedilol 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81406, 81479).  
You asked the Plan to pre-approve genetic testing. You say that the requested services are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested services are 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 genetic testing. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that it remains unclear how the requested testing would be expected to impact the enrollee's 
care or management. The requested testing is still not generally performed within clinical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (81406, 81479).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal testing provided June 19, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that you are appealing the decision that Guardant 
Reveal is experimental and investigational and requesting processing of the claim  The Plan denied your 
request. The Plan says this test investigational and is not covered by Medicare. 
 
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. Per DEX Diagnostics, Guardant Reveal is not covered by Medicare. 
Per National Comprehensive Cancer Network (NCCN) guidelines for colon cancer, version 2.2023, there is 
insufficient data to recommend post-surgical circulating tumor deoxyribonucleic acid (ctDNA) to estimate risk 
of recurrence or determine adjuvant therapy. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Guardant Reveal testing provided June 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601) purchased August 23, 2023. 
 
You asked the Plan to pay for the CPAP device. You say that you were informed by the sleep clinic that it 
would take 2 weeks to send the request to a company that supplied the machines, so you ordered from this 
provider because you needed the machine immediately. The Plan denied your request. The Plan says this item 
was purchased from a supplier who is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure 
(CPAP) device (E0601) purchased August 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the wheelchair (K0001) and sales tax (S9999), purchased on 
June 22, 2023. 
 
You asked the Plan to pay for  the wheelchair and sales tax. You say that the item was medically necessary. 
The Plan denied your request. The Plan says standard power wheelchairs are only available as capped rental 
items. Lump-sum purchase is not permitted.  
 
The Plan must follow Medicare rules. The rules say that as of January 1, 2011, standard power wheelchairs are 
only available as capped rental items. Lump-sum purchase is not permitted.  
 
In this case, the Plan has approved coverage for rental of a power wheelchair. We encourage you to contact the 
Plan to arrange for rental of a power wheelchair. However, the power wheelchair you have requested cannot be 
provided through a lump-sum purchase. Therefore, we decided that the Plan does not have to pay for  the 
wheelchair (K0001) and sales tax (S9999), purchased on June 22, 2023.