Persius/hicric huggingface dataset:
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 admission is medically necessary. The Plan denied 
your request. The Plan says your condition does not meet all of the requirements for inpatient rehabilitation 
admission. The Plan says services may be provided at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail either Monovisc, Orthovisc, Synvisc, or 
Synvisc One first. 
 
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 Euflexxa. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of either 
Monovisc, Orthovisc, Synvisc, or Synvisc One before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the 
plan's required drug(s) 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Group 4 power wheelchair (PWC) repairs. 
 
You asked the Plan to pre-approve the PWC repairs. You say that you need replacement parts for your 
wheelchair. You say that you do not want a new chair when repairs can and should be made. The Plan denied 
your request. The Plan says repairs for a Group 4 power wheelchair cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that group 4 power wheelchairs (PWCs) (K0884) 
have added capabilities that are not needed for use in the home and therefore are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PWC repairs have not been met. Specifically, repairs are not covered for a PWC that is not 
covered. Therefore, we decided that the Plan does not have to pre-approve Group 4 power wheelchair (PWC) 
repairs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous glucose monitor provided 
on January 26, 2023. 
 
You asked the Plan to waive the coinsurance for the continuous glucose monitor. You say that this has been 
reprocessed, and you did not get an explanation as to why your cost share increased. 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 15% 
coinsurance for in-network durable medical equipment. 
 
You have been asked to pay 15% coinsurance for the continuous glucose monitor. This item/service falls 
within the in-network durable medical equipment 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 
coinsurance for the continuous glucose monitor provided on January 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87900, 87798, 87798, 87640, 87652, 87653, 
87481, 89899, 87500) provided on August 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87900, 87798, 87798, 87640, 87652, 87653, 87481, 89899, & 87500 are not supported 
in the medical record. Specifically, multiple unbundled codes were billed for a single panel. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (87900, 87798, 87798, 87640, 87652, 87653, 87481, 
89899, 87500) provided on August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81162). 
 
You asked the Plan to pre-approve the genetic testing. You say that this service is medically necessary. The 
Plan denied your request. The Plan says there is no personal history of cancer. This test is for screening 
purposes and is non-covered. 
 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, the genetic testing, is being requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-
approve genetic testing (81162).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy with lesion removal (45385) and patient 
documented not to have experienced any of the following events: a burn prior to discharge; a fall within the 
facility; wrong site/side/patient/procedure/implant event; or a hospital transfer or hospital admission upon 
discharge from the facility (G8907) provided on July 12, 2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for the colonoscopy and patient documented not to have experienced any events. 
You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan 
says the enrollee has no OON benefits. 
 
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 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 colonoscopy with lesion removal (45385) and 
patient documented not to have experienced any of the following events: a burn prior to discharge; a fall within 
the facility; wrong site/side/patient/procedure/implant event; or a hospital transfer or hospital admission upon 
discharge from the facility (G8907) provided on July 12, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda and Cyramza. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of non-
small cell lung cancer (NSCLC). The Food and Drug Administration (FDA) has not approved the use of 
Keytruda and Cyramza for this indication. The use is not supported by a Medicare-approved journal or compendia. The services are therefore not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda and Cyramza.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit, and related services 
provided on May 8, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the clinic visit, and related services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says enrollees must receive their care from a network 
provider. 
 
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 
items/services 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 hospital outpatient clinic visit, and related 
services provided on May 8, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for polycarbonate lenses (V2784), anti-
reflective coating (V2750) and progressive lenses (V2781) provided on March 20, 2023. 
 
You asked the Plan to waive the copayment for polycarbonate lenses (V2784), anti-reflective coating (V2750) 
and progressive lenses (V2781). You say that you do not feel that you should have to pay as you were not 
given correct information when you agreed to purchase the glasses. The Plan denied your request. The Plan 
says because you received upgrades, these were not considered standard. The Plan also says that the claim 
processed correctly according to your contract. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers lenses when those lenses are standard only. 
 
We looked at the file and the Plan's rules. The Plan rules say the Plan covers one pair of standard eyeglass 
frames and standard plastic eyeglasses lenses per calendar year. Lens enhancements are excluded from this 
benefit. Based on this information, we decided that the Plan's rules for coverage of polycarbonate lenses 
(V2784), anti-reflective coating (V2750) and progressive lenses (V2781) have not been met. Therefore, we 
decided that the Plan does not have to waive the copayment for polycarbonate lenses (V2784), anti-reflective 
coating (V2750) and progressive lenses (V2781) provided on March 20, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says that the Medicare criteria was not met. 
 
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. Specifically, the Plan did not collect medical records from their participating 
provider who ordered the requested CGM. Participating providers are considered agents of the Plan. Without 
this necessary documentation we are unable to make a determination as to whether the enrollee has met the 
criteria for coverage of a CGM. Therefore, we decided that the Plan has to pre-approve a continuous glucose 
monitor (CGM).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ONDANSETRON. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. 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 ONDANSETRON.   
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 You asked the Plan to pre-approve Injectafer . You say that the requested INJECTAFER is medically necessity 
for the enrollee's treatment for iron deficiency anemia.  The Plan denied your request. The Plan says the step 
therapy criteria has 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. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the Plan requires a trial of drugs Infed (iron dextran) and Venofer (iron sucrose) 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infectious agent detection provided on June 06, 2023. 
 
You asked the Plan to pay for Infectious agent detection. You say that you are requesting reconsideration of the 
claim stating laboratory received specimen from the plan contracted provider that the member went to see, and 
therefore lab services should be covered. 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 Infectious agent 
detection provided on June 06, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network computed tomography (CT) 
scan of the abdomen and pelvis provided on May 15, 2023. 
 
You asked the Plan to waive the copayment for an in-network computed tomography (CT) scan of the abdomen 
and pelvis. You say that you went to urgent care and paid your copayment, and now youre getting another bill. 
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 $105 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $105 copayment for an in-network computed tomography (CT) scan of the 
abdomen and pelvis. This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 in-network computed 
tomography (CT) scan of the abdomen and pelvis provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visit, laboratory (lab) work, and 
electrocardiogram provided from June 21, 2023, to June 23, 2023. 
 
You asked the Plan to reimburse you for the outpatient services. You say that you were not informed about 
providers who have opted out of Medicare. You say that you were experiencing back pain and could not get in 
to see your primary care provider right away. You also say that the provider in this case was able to see you 
sooner. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The 
Plan also says that payment cannot be made for services performed by a provider that has opted out of 
Medicare. 
 The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the office visit, laboratory (lab) work, and electrocardiogram provided from June 21, 2023, to June 23, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for an electrocardiogram provided on June 12, 2023. 
 
You asked the Plan to pay for the electrocardiogram. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the diagnosis code reported on the claim does not support the 
medical necessity of procedure code 93005. 
 
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. Specifically, the Plan has not provided a coding rule or a Medicare rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for an electrocardiogram provided on 
June 12, 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: Transportation
Decision: Favorable

 
We decided that the Plan has to increase the reimbursement for the ambulance and emergency services 
provided from March 27, 2023, to March 28, 2023. 
 
You asked the Plan to increase the reimbursement for the ambulance and emergency services. You say that the 
reimbursement was not processed correctly due to the currency conversion. The Plan denied your request. The 
Plan says that you were reimbursed the correct amount. 
 
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. The Plan did not provide the correct Evidence of Coverage (EOC). Without the 
correct EOC we are unable to verify your worldwide coverage benefits. Therefore, we decided that the Plan has 
to increase the reimbursement for the ambulance and emergency services provided from March 27, 2023, to 
March 28, 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.