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

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on March 
30, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $350 
copayment for outpatient surgery/outpatient hospital. 
 
You have been asked to pay a $350 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/outpatient hospital 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 outpatient surgery provided on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the virtual care visit provided on March 3, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the virtual care visit. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this 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 virtual care visit provided on March 3, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that that the test is essential in finding out where the 
enrollee's pain is coming from and to help improve their quality of life. The Plan denied your request. The Plan 
says a lumbar epidural steroid injection 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 the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the two prior epidural steroid 
injections did not produce significant pain relief, therefore it is unlikely that a third injection will work. 
Specifically, the LCD requires 50% pain relief for 3 months , which was not achieved. Therefore, the request is 
not medically 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EEG provided on March 28, 2023, to April 4, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the EEGs. You say that you are requesting reconsideration of the denied claims. 
The Plan denied your request. The Plan says these services were 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 EEG provided on March 28, 2023, to April 4, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has medication failure. The 
Plan denied your request. The Plan says the enrollee has not failed regular treatment.  
 
The Plan follows Medicare rules. Medicare rules say that transcranial magnetic stimulation is only covered 
under certain medical indications. 
 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 requested services. Our physician 
reviewer found that the enrollee had been tried on Abilify, Lexapro, lithium, Wellbutrin, fluoxetine, and 
ketamine infusions. There is no documentation of this enrollee undergoing psychotherapy. Based on the 
information provided, the enrollee does not meet the clinical criteria as she has not undergone a complete 
medical trial and there is no documentation of the patient undergoing psychotherapy. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve transcranial magnetic stimulation.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
documentation does support that the requested device is medically reasonable or necessary. Our physician 
reviewer found you have severe COPD with chronic respiratory failure, with both features of hypercapnia and 
hypoxemia. You also have obstructive sleep apnea and pulmonary hypertension. The documentation does 
support that you have failed bilevel positive airway pressure (BIPAP) with titration study and standard of care 
dictates that you should receive Intelligent Volume Assured Pressure Support (iVAPS) ventilation or 
equivalent. You have failed both CPAP and BIPAP and therefore, home ventilation is the next step. Therefore, 
you meet criteria for the requested device. 
 
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 ventilator have been met. Therefore, we decided that the Plan has to pre-
approve a ventilator.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide.  
 
You asked the Plan to pre-approve a stair glide. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novolog. 
 
You asked the Plan to pre-approve the medication. You say that you have been dependent on Novolog insulin 
for 50 years and use an insulin pump. You also say that it has been broadcast through the news that no senior 
will pay more than $30.00 per month for insulin. The Plan denied your request. The Plan says Novolog 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 Novolog.  
 
Benefits for the medication 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: 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 the enrollee does not meet criteria for admission to an 
IRF.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator and related supplies to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a home ventilator and related supplies. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for 
OON services have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a home ventilator and related supplies to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block injection. 
 
You asked the Plan to pre-approve a genicular nerve block injection. You say that the injection is medically 
necessary to maintain the enrollee's function independence and quality of life. The Plan denied your request. 
The Plan says the service requested is generally not accepted for the suggested use and is considered to be 
experimental/investigational. 
 
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 genicular nerve block injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The service requested is not 
recommended because the elements of the coverage criteria are not satisfied. 
 
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 genicular nerve block injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a genicular nerve block injection.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on April 8, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you have provided the trip notes that 
support the billing of the diagnoses. The Plan denied your request. The Plan says you billed this claim with an 
inappropriate pair of diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of T14.90XA and T07.XXXA. Code T14.90XA is an 
Excludes1 code under code T07.XXXA, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services provided on April 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an OON provider.  
 
You asked the Plan to pre-approve the office visits. You say that the enrollee needs to remain in your care. The 
Plan denied your request. The Plan says these services can be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The record shows you are not a network provider with the Plan. The Plan has network providers available who 
can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit 
to be provided by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 22, 2022, to 
April 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that your organization had a software 
issue that prevented you from billing NOA claims timely.  The Plan denied your request. The Plan says the 
claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 22, 2022, to April 
20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bevacizumab and trametinib. 
 
You asked the Plan to pre-approve bevacizumab and trametinib. You say that you are requesting 
reconsideration of denied chemotherapy services. The Plan denied your request. The Plan says the use of 
bevacizumab and trametinib is not supported in the National Comprehensive Cancer Network (NCCN) 
guidelines. 
 
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 bevacizumab and trametinib. Our 
physician reviewer found the requested use of bevacizumab and trametinib is not Food and Drug 
Administration-approved for the enrollee's diagnosis and is not supported by one of the major drug compendia 
or by a CMS-approved medical journal. The use of bevacizumab and trametinib in this case does not meet 
Medicare criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bevacizumab and trametinib have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bevacizumab and trametinib.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's condition is not routine. 
The Plan denied your request. The Plan says this is not the standard of care for prostate cancer.  
 
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 requested services. Our physician 
reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical 
advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible 
advantage of this expensive therapy. Therefore, the request is 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that it is clear that the enrollee qualifies for 
this procedure. The Plan denied your request. The Plan says this procedure is considered experimental. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
joint disease or foraminal stenosis. The cause of pain is also unclear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Silodosin. 
 
You asked the Plan to pre-approve Silodosin. You say that you disagree with the Plan's denial. 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 Silodosin.   
Benefits for Silodosin may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.