Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair with multiple power options and 
accessories. 
 You asked the Plan to pre-approve a power wheelchair with multiple power options. You say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not have a 
qualifying diagnosis causing mobility limitation for which a Group 3 power wheelchair is needed. The Plan 
also says there is no medical need for the requested multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a power wheelchair with multiple power options may 
be covered when certain criteria are met. 
 
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 power wheelchair with multiple 
power options. Our reviewer says that the requested power wheelchair with multiple power options is not 
medically necessary. Our physician reviewer found the provided records do not support that the enrollee has 
high risk for skin breakdown, uses a catheter intermittently, has spasticity or requires an alternative means of 
managing power drive. Therefore, the reviewer found that the requested power wheelchair with multiple power 
options 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 a power wheelchair with multiple power options have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a power wheelchair with multiple power options and 
accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit provided on March 31, 2023. 
 
You asked the Plan to pay for the rest home visit. You say that the assisted living facility is responsible to 
obtain prior authorization for all of their patients, which should also cover for the medical treatments. 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 rest home visit 
provided on March 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee wants to try single agent 
immunotherapy to try to improve symptoms and extend life. The Plan denied your request. The Plan says the 
medication is not medically necessary. 
 
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 physician reviewer 
found the requested use of Opdivo is not FDA-approved for the enrollees diagnosis because no PDL1 testing 
or plans to use with other treatments such as platinum based therapy or ipilimumab.  The use is not supported by one of the major drug compendia or by clinical research that appears in a Centers 
for Medicare & Medicaid Services (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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Opdivo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on July 20, 2023. 
 
You asked the Plan to waive the copayment for the 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 $30 
copayment for vision care. 
 
You have been asked to pay a $30 copayment for the office visit. This item/service falls within the vision care 
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 office visit provided on July 
20, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
September 07, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you believe you 
should not have a cost share as you received inadequate care. 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 $125 
copayment for emergency care. 
 
You have been asked to pay a $125 copayment for the emergency room services. This item/service falls within 
the emergency care 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 emergency room 
services provided on September 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) (90869, 90868, 
90867). 
 
You asked the Plan to pre-approve TMS. 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 follows Medicare rules. Medicare rules say that TMS may be covered if prescribed and administered 
by a licensed physician under direct supervision who is trained and experienced in the use of repetitive 
transcranial magnetic stimulation. 
 
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 TMS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the information provided, this 
enrollee does not meet the clinical criteria for the use of Transcranial Magnetic Stimulation (TMS) therapy as 
she does not have a diagnosis of major depressive disorder, an adequate medication trial and the order not 
written by a MD or DO. The use of Transcranial Magnetic Stimulation (TMS) is not considered reasonable or 
medically 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 TMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transcranial magnetic stimulation (TMS) (90869, 90868, 90867).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and a core build-up (D2950) for tooth 
#18. 
 
You asked the Plan to pre-approve D2740 and D2950. You say that you need this dental work. The Plan denied 
your request. The Plan says the requested dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2740) and a core build-up (D2950) for tooth #18.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CustomNext Cancer genetic testing panel (81479). 
 
You asked the Plan to pre-approve CustomNext Cancer genetic testing. You say that this gene test is medically 
necessary as the enrollee has a history of recurrent pancreatitis dating back ten years. The Plan denied your 
request. The Plan says the records provided indicate that the enrollee has no personal history of cancer; 
therefore, this genetic test would be considered a screening which is not covered by Medicare. There is no 
reason provided to suggest why a standard screening or test would not be acceptable in this case. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, CustomNext Cancer genetic testing, is being requested solely for screening 
purposes. The records provided indicate that the enrollee has no personal history of cancer. This means the test 
would be performed as a screening in this case. Medicare does not cover this test solely for screening purposes. 
Medicare requires that a patient has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV 
cancer in order to cover/provide genetic cancer testing. Therefore, we decided that the Plan does not have to 
pre-approve CustomNext Cancer genetic testing panel (81479).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service August 3, 
2023. 
 You asked the Plan to pay for procedure code 99283. The Plan denied your request. The Plan says payment for 
code 99283 is bundled into payment for code 99285. 
 
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 99283 
is a column II code to column I code 99285. 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 99283 billed for date of service August 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 28, 2022, 
at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code G93.6, described as 
cerebral edema. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that documentation does not support the billed code. 
Our physician reviewer found that the enrollee is a 73-year-old female who was admitted and treated for 
metastatic cancer. Head imaging showed some edema; however, right eye blurriness was reported. There was 
no documented treatment for the edema to support this secondary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 28, 2022, at the Diagnosis Related Group (DRG) 
originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for orthopedic visits provided on July 05, 
2023, to August 30, 2023. 
 
You asked the Plan to waive the coinsurance for orthopedic visits. You say that you did not know this provider 
was out-of-network. No one told you he was, in fact the office told you they were in-network. 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 45% 
coinsurance for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 45% coinsurance for orthopedic visits. This item/service falls within the 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. The total you owe is $352.28 ($130.12 + $92.04 + 
$130.12 = $352.28). Therefore, we decided that the Plan does not have to waive the coinsurance for orthopedic 
visits provided on July 05, 2023, to August 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 30, 2022, 
to January 11, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says the medical 
records did not have sufficient documentation to clinically validate the diagnosis of code A41.9 (sepsis, 
unspecified organism). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
In this case, you billed the inpatient services provided with principal diagnosis code, A41.9 defined as sepsis, 
unspecified organism. 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 inpatient hospital 
services at the DRG originally billed. Our physician reviewer found the patient did not meet the Sepsis-3 
criteria as there was insufficient evidence of organ failure directly related to a dysregulated response to 
infection. Therefore, diagnosis code A41.9 (sepsis) is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 30, 2022, to January 11, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided on May 10, 2023, to May 13, 2023. 
 
You asked the Plan to pay for the inpatient hospital care the inpatient care. You say that the service was billed 
correctly and should be paid. The Plan denied your request. The Plan says that the enrollee has exhausted the 
maximum allowed for the inpatient stay. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that while the Plan did show that 120 inpatient days were used in a 
single benefit period, from April 6, 2022, through the stay ending on May 10, 2023, there is no documentation 
supporting that the enrollee's lifetime reserve days had been used by this date. Therefore, we decided that the 
Plan has to pay for the inpatient hospital care provided on May 10, 2023, to May 13, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain (70553) 
provided on March 29, 2023. 
 
You asked the Plan to pay for the MRI. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says some ICD-10-CM codes indicate laterality, specifying whether the 
condition occurs on the left, right or is bilateral. The code billed does not indicate a specific side that is being 
treated. 
 We looked at the file and Medicare rules. The unspecified code can only be used if the records do not specify a 
side. In this case, the medical records clearly states that it was the right ear that has the hearing loss and gives 
the correct diagnosis code that should have been used. Therefore, the unspecified code is not appropriate. 
Based on this information, we decided that Medicare rules for payment of this claim have not been met. 
Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the 
brain (70553) provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided by a Licensed Professional 
Counselor (LPC). 
 
You asked the Plan to pay for psychotherapy. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that their original decision to deny payment was correct. The Plan must follow Medicare rules. Medicare rules say that in order to receive payment for covered items or 
services, a provider must be enrolled in Medicare. A Licensed Professional Counselor (LPC) is not eligible to 
enroll in the Medicare program so is not payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Therefore, we decided that the Plan does not have to pay for 
psychotherapy provided by an LPC.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion surgery. 
 
You asked the Plan to pre-approve spinal fusion. You say that the enrollee meets the diagnosis requirements for 
this service.  The Plan denied your request. The Plan says that it 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 spinal fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has lumbar stenosis without spinal instability. Spinal fusion surgery is not 
clinically 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 spinal fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal fusion surgery.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva (J0897). 
 You asked the Plan to pre-approve Xgeva. You say that you believe your physician is suggesting this 
medication is best suited for you and your condition during this difficult time and with your age. The Plan 
denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for Xgeva. 
 
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 Xgeva. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of intravenous 
pamidronate or zoledronic acid before they will approve the requested drug. In this case, you have not tried and 
failed the required drugs. Our reviewer also found that there is no documentation provided indicating that the 
Plans required drugs would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva (J0897).