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

 
We decided that the Plan has to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says that coverage criteria has not been met. 
 
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 Zilretta. Our reviewer says that Zilretta 
is medically necessary. Our physician reviewer found  the record indicates that the enrollee has a diagnosis 
of  knee pain due to x-ray documented osteoarthritis.  The Food and Drug Administration has  stated that the 
requested drug is indicated for the enrollee's 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 Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
Zilretta.  
 
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 pre-approve endoscopic rhizotomy. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested code does not match the stated requested service. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that endoscopic rhizotomy is experimental for back pain. More research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endoscopic rhizotomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stress test and an injection provided on January 17, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a stress test and an injection. You say that these services do not require 
authorization. The Plan denied your request. The Plan says out-of-network services require authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a stress test and an injection provided on January 
17, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durvalumab. You asked the Plan to pre-approve the medication. You say that due to the enrollee's medical condition, you 
believe this medication is the best course of action. The Plan denied your request. The Plan says the criteria for 
coverage have 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 the medication. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has stage IIb non-small cell lung cancer and has received radiation treatment with no chemotherapy or surgical 
intervention planned. The FDA has not stated that the requested drug is indicated for the enrollee's condition. 
The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve durvalumab.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bortezomib. 
 
You asked the Plan to pre-approve Bortezomib. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. 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 Bortezomib. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of Bortezomib is not 
FDA-approved for the enrollees diagnosis. Its use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Bortezomib have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Bortezomib.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health services rendered from November 30, 
2022, to December 12, 2022. 
 You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says treatment needs can be met in less restrictive settings. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable and necessary. Our physician reviewer found that it 
was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did 
not have suicidal or homicidal ideation, auditory or visual hallucinations. The enrollee was compliant with 
treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to 
have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the 
dates in question as the enrollee did not have dangerousness to self or others and was compliant with her 
treatment. The health plans denial of continued inpatient psychiatric services is appropriate. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient mental health services rendered from November 30, 2022, to December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no new or worsening symptoms, and no stroke or syncope. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke 
or any other apparent indication for an ILR. In summary, there is insufficient documentation to support the 
medical necessity for insertion of an ILR in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on January 5, 2023, by an out-
of-network provider. 
 
You asked the Plan to pay for the out-of-network vision services. You say that this was your second visit, and 
you knew the provider did not take your insurance. The Plan denied your request. The Plan says this provider is 
out-of-network, the services were not referred by a network provider, and the services were not urgent or 
emergent, nor were they approved in advance. 
 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 vision services provided on January 5, 2023, 
by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device (E0935) to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a CPM device. You say that the requested device is necessary after a total 
knee replacement. You are requesting a gap exception authorization. The Plan denied your request. The Plan 
says the enrollee must use network providers for most services except for emergency services and routine 
travel dialysis. The service is available 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 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 continuous passive motion (CPM) device (E0935) 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 pay for an eye refraction provided on February 2, 2022. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this Original 
Medicare doesnt cover routine eye exams (eye refractions) for eyeglasses/contacts. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for procedures performed 
in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not 
covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and Medicare rules. Medicare does not pay for procedures performed in the course of any 
eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay 
for an eye refraction provided on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Part B drugs, echocardiography, imaging 
and office visit on December 14, 2022. 
 
You asked the Plan to waive the cost share for Part B drugs, echocardiography, imaging and office visit. You 
say that you want to appeal the amount being charged. 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 20% 
coinsurance for covered Medicare Part B drugs, including chemotherapy drugs. Covered drugs include drugs 
that usually arent self-administered by the patient and are injected or infused while you are getting physician, 
hospital outpatient, or ambulatory surgical center services. You must pay a 20% coinsurance for monitoring or 
routine Medicare-covered diagnostic tests and procedures including, but not limited to Electrocardiogram 
(ECG/EKG), Electroencephalogram (EEG) and stress test. You must pay $20% coinsurance for Medicare-
covered diagnostic radiology services (e.g., MRI/MRA, CT scans, nuclear cardiology tests). Covered services 
include but are not limited to laboratory tests and other outpatient diagnostic tests, such as ultrasounds. You 
must pay $5 copay for Medicare-covered primary care visits. Covered services include Medically necessary 
medical care or surgery services furnished in a physicians office, certified ambulatory surgical center, hospital 
outpatient department, or any other location. $35.43 + $49.08 + $96.06 + $5 = $185.57. Therefore, results in 
the total cost sharing amount of $185.57. 
 
 
You have been asked to pay a 20% coinsurance for Part B drugs, a 20% coinsurance for echocardiography, 
20% coinsurance for imaging and a $5 copayment for office visit. This item/service falls within the Medicare 
Part B prescription drugs, outpatient diagnostic tests and therapeutic services and supplies and 
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 cost share for Part B drugs, echocardiography, imaging and office visit on December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 16, 2023, to 
March 10, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. 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 January 16, 2023, to 
March 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service provided on July 21, 
2021. 
 
You asked the Plan to waive the copayment for the ambulance service. You say that the ambulance was 
ordered by your provider, and you do not feel you should have to pay. 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 $275 
copayment for ground ambulance services. 
 
You have been asked to pay a $275 copayment for the ambulance service. This item/service falls within the 
ground ambulance 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 copayment for the 
ambulance service provided on July 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on March 
16, 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 $325 
copayment for outpatient surgery/outpatient hospital facility visit. 
 
You have been asked to pay a $325 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/outpatient hospital facility visit 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 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
March 08, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. You say that the 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 a home visit for the 
evaluation and management provided on March 08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 2, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that you disagree with the denial. 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 88341 is 13. The MAI value for this code is 3. You billed 17 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service February 2, 2023.