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

 
We decided that the Plan does not have to pre-approve durvalumab. 
 
You asked the Plan to pre-approve durvalumab. You say that the services are medically necessary as the 
enrollee demonstrated toxicity on pembrolizumab. The Plan denied your request. The Plan says the criteria for 
approval has not been met. 
 
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 durvalumab. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found requested use of durvalumab is not Food 
and Drug Administration-approved for the enrollee's diagnosis of adenocarcinoma of the esophagus. The use of 
durvalumab is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal for the specifics of this patient's diagnosis and condition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of durvalumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve durvalumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes Q9965, 64447 and 64450 billed for date of 
service March 28, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the diagnosis 
codes do not meet billing requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code Q9965 has a status indicator of N on the outpatient hospital prospective payment 
system. Payment for this service is packaged into payment for other services. We find that CPT codes 64447 
and 64450 were billed with diagnosis codes G89.29 and M16.12. These diagnosis codes are not among those 
that support medical necessity of the services. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes Q9965, 64447 and 64450 billed for date of service March 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department services provided on April 23, 
2022. 
 
You asked the Plan to pay for the emergency department services. The Plan denied your request. The Plan says 
this claim was denied correctly. 
 
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 emergency department services 
provided on April 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services provided on January 
05, 2023. 
 
You asked the Plan to waive the copayment for the specialist services. You say that you disagree with the 
copayment. 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 a $50 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $50 copayment for the specialist services. This item/service falls within the in-
network physician/practitioner services, including doctors office visits benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the specialist services provided on January 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service February 7, 
2023.  You asked the Plan to pay for procedure code 88374. You say that the lab reports validate the number of units 
billed. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 3. You billed 9 units of this 
code, exceeding the MUE. The documentation did not provide sufficient rationale as to why additional units 
were needed. Based on this information, we decided that Medicare rules for coverage of procedure code 88374 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88374 billed 
for date of service February 7, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's chance to return home and maintain 
living at home will be significantly reduced if denied.  The Plan denied your request. The Plan says that the 
enrollee does not meet the requirements. Services needed may be provided safely in a lower level of care. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee's condition is in fact complex and fragile, and there is every reason to expect participation in 
and benefit from services, inpatient rehabilitation admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5298), miscellaneous hearing service 
(V529) and sales tax (S9999) provided on March 3, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5298), miscellaneous hearing service (V529) and sales tax 
(S9999). You say that you were unaware that hearing coverage is not available if provided by an out-of-
network provider when no other coverage in our plan has that stipulation. The Plan denied your request. The 
Plan says the hearing benefit is not covered if the services are not ordered through this designated vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased in-network.  
 
 
  We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5298), miscellaneous hearing service (V529) and sales tax (S9999)  have not been 
met. Therefore, we decided that the Plan does not have to reimburse for hearing aids (V5298), miscellaneous 
hearing service (V529) and sales tax (S9999) provided on March 3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 96365, 96366, 96521, and J1817 for date of service 
February 16, 2023. 
 
You asked the Plan to pay for codes 96365, 96366, 96521, and J1817. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the codes billed are not supported. 
 
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 codes 96365, 96366, 96521, and J1817 are not supported in the medical record. Specifically, 
the medical records indicate that outpatient intravenous insulin treatment was performed. There is more 
appropriate codes to be billed for the services rendered. This means codes 96365, 96366, and J1817 are not 
supported. The documentation shows an order to perform refilling and maintenance of portable pump. 
However, the records indicate that outpatient intravenous insulin treatment was performed. No procedure report for pump maintenance refill was provided in the documentation. This means code 96521 is not supported. 
Based on this information, we decided that Medicare rules for coverage of codes 96365, 96366, 96521, and 
J1817 have not been met. Therefore, we decided that the Plan does not have to pay for codes 96365, 96366, 
96521, and J1817 for date of service February 16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department services provided on February 13, 
2023. 
 
You asked the Plan to pay for the emergency department services. You say that you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says this claim denied correctly because the rendering 
facility is a non-Medicare approved/certified freestanding emergency facility. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare payment cannot be made to a provider 
that is not enrolled in the Medicare program. Medicare rules also say that Medicare covers services in an 
emergency department only if the emergency clinic is affiliated with the hospital.  
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. The documentation provided also states that the facility in question is not an actual hospital and has 
no affiliation with a hospital. Therefore, we decided that the Plan does not have to pay for the emergency 
department services provided on February 13, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that the step therapy 
requirements 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 drug. Our reviewer says that Prolia 
is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drug bisphosphonate. Also, there is no indication that the Plan's required drug would likely be less 
effective 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total electric hospital bed (E0265), bedside rails (E0305), 
gel pressure mattress (E0196) and other accessory (E1399). 
 
You asked the Plan to pay for the hospital bed and accessories. You say that the items should be covered. The 
Plan denied your request. The Plan says these items were obtained through a provider that is not enrolled in 
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 total electric hospital bed (E0265), 
bedside rails (E0305), gel pressure mattress (E0196) and other accessory (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service October 25, 
2022.  You asked the Plan to pay for procedure code 88374. You say that the reports validate the number of units. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. The records do not sufficiently document why the additional units were needed. 
Based on this information, we decided that Medicare rules for coverage of procedure code 88374 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 88374 billed for date of 
service October 25, 2022.
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 are in severe need for intensive physical therapy. 
The Plan denied your request. The Plan says you do not meet the requirements for inpatient rehabilitation. 
Services needed may be provided safely in a lower level of care. 
 
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. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 17, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the service was not authorized. 
 
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 provided on April 17, 2023, by an 
OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says the clinical 
effectiveness has not been demonstrated in peer-reviewed literature.  
 
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 Botox. Our physician reviewer found 
that the enrollee has a history of piriformis syndrome and sciatica. To date, the clinical value and effectiveness 
of Botox in the setting of piriformis syndrome and sciatica have not been demonstrated in the peer-reviewed 
literature. The review has determined that the documentation does not support that Botox is medically 
reasonable or necessary for this enrollee. The documentation does not support that Botox is safe and effective 
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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not medically necessary. 
 
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. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on December 03, 2022. 
 
You asked the Plan to pay for the podiatry services. You say that you were misled about the enrollees 
coverage. 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 the podiatry services 
provided on December 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service November 
21, 2022. 
 You asked the Plan to pay for procedure code 99214. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99214 is bundled into payment for code 20610. 
 
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 99214 
is a column II code to column I code 20610. 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 99214 billed for date of service November 21, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the mental health visits provided from 
March 31, 2022, to August 9, 2022. 
 
You asked the Plan to waive the deductible for the mental health visits. You say that you disagree with the 
deductible 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient mental health care.  
 
 
 
 You have been asked to pay $99.34 toward your deductible for each mental health visit provided on March 31, 
2022, April 15, 2022, April 25, 2022, May 13, 2022, May 27, 2022, June 14, 2022, and July 12, 2022. You 
have also been asked to pay $54.62 towards your deductible for the mental health visit provided on August 9, 
2022. The items or services you asked the Plan to waive the deductible for fall within the outpatient mental 
health care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $750 deductible which applies to outpatient mental health care. This cost sharing is a contractual 
obligation that had not been met at the time the mental health visits was received on March 31, 2022, to August 
9, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the mental health visits 
provided from March 31, 2022, to August 9, 2022.