Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intravitreal injection of a pharmacologic agent 
(67028) and Vabysmo (J2777). 
 You asked the Plan to pre-approve an intravitreal injection and Vabysmo. You say that you are worried about 
your vision, and your ophthalmologist recommended this injection. The Plan denied your request. The Plan 
says this request cannot be approved at this time by Medicare or your health plan. 
 
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 an intravitreal injection and Vabysmo. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the Plan 
requires a trial of drug of at least 3 doses of Avastin and 1 dose of Eylea 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 an intravitreal injection and Vabysmo have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an intravitreal injection of a pharmacologic agent (67028) and 
Vabysmo (J2777).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve seat lift mechanism. You say that you have severe neuropathy in your legs. 
The Plan denied your request. The Plan says the records do not show that you are completely incapable of 
standing up from a regular armchair or any chair in your home. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 seat lift mechanism. Our reviewer says that you do not meet criteria for a seat lift mechanism. Our physician reviewer found you are able to rise from 
chairs in your home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of seat lift mechanism have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a seat lift mechanism.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service October 9, 
2023.  
 
You asked the Plan to pay for procedure code 86077. You say that medical records were provided. 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 code 86077 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 code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service October 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on 
September 06, 2023, to September 23, 2023. 
 
You asked the Plan to pay for the skilled nursing facility (SNF) care. You say that you are requesting 
reconsideration for the service provided. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 skilled nursing facility (SNF) care provided on September 06, 2023, to September 23, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the use of Syfovre 180 units for your right eye. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary for 
your condition.  The Plan denied your request. The Plan says that your right eye does not meet the criteria for 
Syfovre. 
 
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 the medication. Our reviewer says that 
you meet the criteria. Our physician reviewer found in this case; the record indicates that you have geographic 
atrophy secondary to age-related macular degeneration. The FDA has stated that the requested drug is indicated 
for your condition. The elements of the coverage criteria are satisfied. The requested service is recommended. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve the use of Syfovre 180 units for your right eye.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation for your medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 48 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 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 routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 311 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve advance care planning/home care visits (99341, 99342, 
99344, 99345, 99347, 99348, 99349, 99350, 99497, 99498, G0318). 
 
You asked the Plan to pre-approve home health services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the home health aide that is providing the services to the enrollee must have 
a valid agreement to participate in the Medicare program and the enrollee must qualify for coverage of home 
health services. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve advance care planning/home care 
visits (99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99497, 99498, G0318).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on May 22, 2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you thought the payment you 
made at the office was enough. 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 $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for the office visit. 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. Therefore, we decided that the Plan does not have 
to waive the copayment for the office visit provided on May 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a uvulectomy. 
 
You asked the Plan to pre-approve a uvulectomy. You say that a uvulectomy is medically necessary. The Plan 
denied your request. The Plan says a uvulectomy is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a uvulectomy. Our reviewer says that 
the requested uvulectomy is not considered medically reasonable and necessary. Our physician reviewer found 
the record indicates that the enrollee has uvular hypertrophy and globus sensation after viral infection but no 
evidence of obstructive disease or neoplasm. There is insufficient literature to support the safety and efficacy, 
as defined by Medicare rules, of the requested service in the clinical scenario presented. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a uvulectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a uvulectomy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) provided on 
August 10, 2023. 
 
You asked the Plan to waive the copayment for the electrocardiogram (EKG). You say that this cardiology visit 
was considered part of a presurgical testing. 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for the electrocardiogram (EKG). 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. Therefore, we decided that the Plan does not have 
to waive the copayment for the electrocardiogram (EKG) provided on August 10, 2023.
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 IRF services to get stronger before 
returning home. The Plan denied your request. The Plan says you do not meet the criteria for IRF services.  
 
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. Your medical problems 
are stable, and there are no complex nursing or rehabilitation needs. Medically necessary services can be 
provided in a lower level of 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: 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 are requesting an expedited appeal as the 
enrollee meets the full criteria for inpatient acute rehabilitation. The Plan denied your request. The Plan says 
the enrollee does not meet the requirements for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility services provided on August 10, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the skilled nursing facility services. The Plan denied your request. The Plan says  
 
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 had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 skilled nursing facility services provided on August 10, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77080 billed for date of service August 17, 
2023. 
 
You asked the Plan to pay for the billed service. You say that you are not liable to ensure medical criteria are 
met. The Plan denied your request. The Plan says the rules for coverage have not been met. 
 
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, the CPT Code Manual definition of code 77080 is dual-energy X-ray absorptiometry (DXA), bone 
density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine). We find that CPT code 77080 is not 
supported in the medical record. There are insufficient medical records to show that the provided test was 
indicated for the enrollees condition. Based on this information, we decided that Medicare rules for coverage 
of the billed service have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 77080 billed for date of service August 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs the level of care 
provided in an LTACH. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for requested LTACH services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that are unavailable at the acute care 
setting where the enrollee is receiving care. Medically necessary services can be furnished safely and 
effectively in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 20, 
2023. 
 
You asked the Plan to pay for the billed code. You say that separate payment should be allowed. The Plan 
denied your request. The Plan says the code is not payable. 
 
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 looked at the file and the rules. The file shows that a genomic sequence analysis was provided. The Plan 
paid for this testing under code 81455. There are no records to show that more than one testing method was 
provided. The Plan made multiple attempts to obtain additional information with no success. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service February 20, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on July 19, 2023. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that you feel this infection happened 
because of a procedure that went incorrectly. You cannot afford all these bills because you are on a fixed 
income. 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 $295 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. 
 
You have been asked to pay a $295 copayment for an endoscopy. This item/service falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 
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 endoscopy provided on July 
19, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291 and 93010 billed for date of service 
October 29, 2023. 
 
You asked the Plan to pay for the billed services. You say that the modifier is compatible with the code billed. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99291 and 93010 billed for date of service 
October 29, 2023.