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

 
We decided that the Plan does not have to waive the copayments for the substance abuse screening and EKG 
provided on February 16, 2023. 
 You asked the Plan to waive the copayments for the substance abuse screening and EKG. You say that you 
only had a physical exam that day and should not have a 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 $0 
copayment for in-network and out-of-network annual physical exams. Your contract with the Plan also says 
that you must pay a $35 copayment for in-network outpatient substance abuse services. Your contract with the 
Plan also says that you must pay a $25 copayment for in-network outpatient diagnostic tests and procedures, 
including EKGs. 
 
You have been asked to pay a $35 copayment for the substance abuse screening. This item/service falls within 
the outpatient substance abuse services benefit category. You have also been asked to pay $15.62, which is less 
than the standard $25 copayment for the EKG. You have been asked to pay a total of $50.62 ($35 copayment + 
$15.62 copayment = $50.62). 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 the substance abuse 
screening and EKG provided on February 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca (Q5111). 
 
You asked the Plan to pre-approve Udenyca. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the documentation does not include your chemotherapy treatment plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Udenyca. Our reviewer says that the 
requested use of Udenyca is not medically necessary. Our physician reviewer found Udenyca is Food and Drug 
Administration-approved for the prevention of febrile neutropenia, in patients with non-myeloid malignancies 
receiving myelosuppressive chemotherapy associated with a clinically significant incidence of febrile 
neutropenia.  
 Provided records document plans for treatment with fluorouracil, leucovorin, oxaliplatin, and docetaxel but 
records provide no dosing regimen; the risk of febrile neutropenia is dose-dependent with these agents. Without 
documentation of the dosing regimen, it is not clear that the Udenyca is indicated. Therefore, the reviewer 
found that the requested use of Udenyca is not medically reasonable or necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca (Q5111).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided 
December 2, 2022, to December 21, 2022. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that this enrollee's medical 
necessity meets he guidelines that qualify for coverage. The Plan denied your request. The Plan says this item 
is not covered under the Plan's benefits and is excluded from overage.  
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. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for a water circulating heat pad with pump (E0217) provided December 2, 2022, to 
December 21, 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 need rehabilitation to get your strength and 
balance back and to get your life back. The Plan denied your request. The Plan says these services are 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 you are medically stable and do not need a physician's supervision 3 times a week in 
an IRF. Your rehabilitation needs can be safely provided in an alternate and low intensity setting. 
 
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 laboratory services related to end-stage renal disease 
(ESRD) provided on December 27, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Botox injections provided on September 27, 2022. 
 
You asked the Plan to pay for Botox injections. You say that the services rendered are treating a chronic 
condition disorder that has and continues to affect your daily life. The Plan denied your request. The Plan says 
the service requested is not an FDA approved treatment for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 pay for Botox injections. Our reviewer says that the 
treatment provided does not meet the criteria for approval. Our physician reviewer found Botox injections are 
not FDA approved or supported by any major drug company as a treatment for temporomandibular joint (TMJ) 
dysfunction. 
 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 injections have not been met. Therefore, we decided that the Plan does 
not have to pay for Botox injections provided on September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 27, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 27, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health visit provided on November 1, 2022, by an 
OON provider.  
 
You asked the Plan to pay for a mental health 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 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 a mental health visit provided on November 1, 
2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orphenadrine with Aspirin and caffeine. 
 
You asked the Plan to pre-approve the requested medication. You say that the enrollee would benefit from the 
combination product. 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 Orphenadrine with Aspirin 
and caffeine.  
 
Benefits for the requested 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 2, 2021, and 
March 9, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this claim should be paid. The Plan denied 
your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until March 20, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on March 2, 2021, and March 9, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for radiology imaging services provided out-of-area (OOA) on April 3, 
2023, to April 19, 2023, at the in-network benefit level.  
 
You asked the Plan to pay for the OOA radiology imaging services at the in-network benefit level. You say that 
you were assured OOA services would be covered as if they were in-network. You say that the services in 
dispute were initiated from an emergency visit.  The Plan denied your request. The Plan says that the services 
in dispute were provided out-of-network, and that appropriate cost-sharing amounts were applied. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 OOA radiology imaging services at the 
in-network benefit level. Our reviewer says that the criteria for coverage of OOA care at the in-network benefit 
level have been met. Our physician reviewer found the enrollee was hospitalized OOA with sepsis. The 
enrollee was evaluated by Infectious Disease and treated with intravenous (IV) antibiotics. The enrollee could 
not have foreseen requiring the services prior to leaving their service area. The records indicate that the care 
provided was medically necessary and it would not have been medically reasonable to delay the services until 
returning to the service area. 
 
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 OOA radiology imaging services at the in-network benefit level have been 
met. Therefore, we decided that the Plan has to pay for radiology imaging services provided out-of-area (OOA) 
on April 3, 2023, to April 19, 2023, at the in-network benefit level.   
 
 
 
 
 
 
 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on March 2, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77066, 76642, & G0279 billed for date of 
service February 7, 2023.  
 You asked the Plan to pay for procedure codes 77066, 76642, & G0279. You say that this service was 
medically necessary. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 77066, 76642, & G0279 is 1. The MAI value for this code is 2. You billed 
2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 77066, 76642, & G0279 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 77066, 76642, & G0279 billed for date of service February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
March 10, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service March 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for a specialist office visit and an x-ray 
provided on May 12, 2023. 
 
You asked the Plan to reduce the deductible for a specialist office visit and an x-ray. You say that these 
services should be charged at the in-network benefit level. 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 $500 deductible which applies to an out-of-network specialist office 
visit and an x-ray. You have been asked to pay $175.76 towards the deductible for the specialist office visit. The item or service 
you asked the Plan to reduce the deductible for falls within the physician/practitioner services, including 
doctor's office visits benefit category. You have also been asked to pay $37.10 for the x-ray. The item or 
service you asked the Plan to reduce the deductible for falls within the outpatient diagnostic tests and 
therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $500 deductible which applies to out-of-network physician/practitioner services, 
including doctor's office visits and out-of-network outpatient diagnostic tests and therapeutic services and 
supplies. This cost sharing is a contractual obligation that had not been met at the time a specialist office visit 
and an x-ray was received on May 12, 2023. Therefore, we decided that the Plan does not have to reduce the 
deductible for a specialist office visit and an x-ray provided on May 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 100 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional transportation trips. You say that you have run out of 
transportation rides for the year and you have upcoming dialysis appointments which occur 3 times a week. 
The Plan denied your request. The Plan says your benefit only allows 48 trips for this service. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve additional 
transportation trips as you have run out of trips. Based on this information, we decided that you have exhausted 
the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve 100 additional routine transportation trips (A0120).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Gelsyn-3 (J7328). 
 You asked the Plan to pre-approve Gelsyn-3. You say that Gelsyn-3 is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Gelsyn-3 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 Gelsyn-3. Our reviewer says that 
Gelsyn-3 is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a trial of drugs Orthovisc or Supartz FX 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Gelsyn-3 (J7328).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 3 CGM sensor. You say that the enrollee needs the 
requested CGM to manage his diabetes. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for approval of the requested GM sensor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 3 CGM sensor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) sensor.