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

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. 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. 
 
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 Vabysmo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative.  The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on May 03, 2023, to May 24, 
2023. 
 
You asked the Plan to pay for chiropractic services. You say that chiropractic services should be covered under 
your plan, so you do not understand why payment was denied. 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 chiropractic services 
provided on May 03, 2023, to May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor kit. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 sensor kit. You say that the enrollee is very weak and 
is high risk for falls. You also say that the enrollee was recently started on insulin. The Plan denied your 
request. The Plan says conditions for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have a history 
of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage of the 
FreeStyle Libre 2 sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 2 sensor kit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a femtosecond laser with limbal relaxing incisions. 
 
You asked the Plan to pre-approve laser eye surgery. You say that without this procedure your quality of life 
would decrease. The Plan denied your request. The Plan says this procedure is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laser eye surgery have not been met. Therefore, we decided that the Plan does not have to pre-
approve a femtosecond laser with limbal relaxing incisions.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve physical therapy. You say that the in-network facilities do not have 
providers who can treat the enrollee. The Plan denied your request. The Plan says the service can be provided 
by an in-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 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 
physical therapy visits to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on March 07, 2023. 
 
You asked the Plan to waive the copayment for an injection. You say that you should not be responsible for the 
copayment because the provider billed the medication prescription incorrectly. 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 $25 
copayment for physician/practitioner services. 
 
You have been asked to pay a $25 copayment for an injection. This item/service falls within the 
physician/practitioner 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 
an injection provided on March 07, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 21, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be covered. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan (93978) billed for date of service April 21, 
2023. 
 
You asked the Plan to pay for a duplex scan. You say that this was billed correctly. The Plan denied your 
request. The Plan says this is not supported in the records. 
 
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 93978 is duplex scan of aorta, inferior vena cava, iliac 
vasculature, or bypass grafts; complete study. 
 
We asked our coder 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 a duplex scan. Our reviewer says that this code is not 
supported. Our reviewer found the procedure report does not include sufficient documentation of arterial inflow, venous outflow and color, and spectral doppler to confirm a complete duplex scan. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pay for a duplex scan (93978) billed for date of service April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Therapy (PBT) (77014x10, 77520x10, 
77522x10, 77523x10, 77525x10, G6002x10) 
 
You asked the Plan to pre-approve PBT. You say that the enrollee has a life-threatening cancer diagnosis. 
Treating her with partial breast irradiation to the right breast cancer post right breast lumpectomy is medically 
necessary for 10 fractions of PBT. The Plan denied your request. The Plan says PBT is not reasonable and 
necessary, as the enrollee's condition does not meet the plan's policy. 
 
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 PBT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a proton is the charged nucleus of a hydrogen atom (hydrogen atom minus an electron).   
Charged particles (such as protons and carbon) can be used to deliver therapeutic radiation.  Standard 
radiation is delivered with a linear accelerator (LINAC), which delivers photon therapy (akin to high energy 
light), while protons (and other charged particles) are generated from a cyclotron.  The difference between 
proton and photon irradiation is that the protons (or charged particles) stop abruptly in the tissue (Bragg peak) 
so there is less exit dose through normal tissue. The use of proton therapy is an accepted radiation technology, 
that has proven efficacy and tolerability. Certain conditions such as base of skull chordomas and 
chondrosarcomas, and pediatric central nervous system (CNS) malignancies are probably best treated with 
proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing 
the neighboring normal tissue. When treating enrollees with complex target volumes and/or when needing to 
treat internal mammary, supraclavicular and axillary nodes, proton therapy may yield a better dose distribution 
that is clinically meaningful. For this enrollee, the records describe a case control comparison plan with 
proton therapy vs. photon (not specified if with using deep inspiration breath hold or if an intensity-modulated 
radiation therapy (IMRT) plan with optimal selection of beam angles was attempted).  Screen captures show 
isodose lines. Dose-volume histograms are also included as is a summary table. The decision is unfavorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Therapy (PBT) (77014x10, 77520x10, 77522x10, 77523x10, 77525x10, G6002x10)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an in-network specialist visit, and an 
outpatient rehab visit provided on January 13, 2023, and February 9, 2023. 
 
You asked the Plan to waive the copayments for an in-network specialist visit and an outpatient rehab visit. 
You say that you should not have to pay these copayments. 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, and a $40 copayment for 
outpatient rehabilitation service.  You have been asked to pay the allowed amount of $30.16 which is less than the $40 copayment for outpatient 
rehab services. You had two visits resulting in the $75.16 total copayment ($45 + $30.16 = $75.16).  
 
You have been asked to pay a $75.16 copayment for an in-network specialist visit and an outpatient rehab visit. 
This item/service falls within the Physician/Practitioner services, including doctors office visits, and outpatient 
rehabilitation service 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 copayments for an in-
network specialist visit, and an outpatient rehab visit provided on January 13, 2023, and February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on April 18, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this patient is in a facility, and you depend upon the 
facility staff for any verification or prior authorization. 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 facility visit provided 
on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barricaid device (22899, C9757). 
 
You asked the Plan to pre-approve a Barricaid device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 Barricaid device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found no compelling rationale is presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested Barricaid device 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 Barricaid device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Barricaid device (22899, C9757).
Appeal type: Drugs
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 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 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 Euflexxa. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee received the requested 
injection in June, 2023, which is less than six months ago. The Food and Drug Administration has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements 
of the coverage criteria are not satisfied. The requested service cannot be 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J3490 for date of service March 29, 2023. 
 
You asked the Plan to pay for code J3490. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the service at issue was not billed with the required modifier to allow separate 
payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 27096 
provided on the same date of service. We find that the service at issue may be unrelated to the surgical 
procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these 
services have not been met. Therefore, we decided that the Plan does not have to pay for code J3490 for date of 
service March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the additional therapeutic massage visits. 
 
You asked the Plan to pre-approve the additional therapeutic massage visits. You say that the massage therapy 
is the only treatment that works and loosens up your muscles. You say your muscles have atrophied. The Plan 
denied your request. The Plan says that the benefit has been exhausted. 
 
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 send documentation showing that six therapeutic 
massage services were received and that the benefit has been exhausted. This means we cannot determine if the 
Plan's denial of the additional massage therapy visits is supported. Therefore, we decided that the Plan has to 
pre-approve the additional therapeutic massage visits.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is in need of a ventilator 
because it provides assured pressure support and tidal volume which a bilevel does not provide. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for a home mechanical ventilator. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
for an exacerbation of COPD. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. A 
home ventilator was prescribed because of carbon dioxide (CO2) retention, but there is no arterial blood gas 
(ABG) done while stable to document chronic CO2 retention. If that is present, the enrollee may benefit from 
BiPAP with average volume assured pressure support (AVAPS) during sleep as an outpatient. Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP. Of note, the enrollee has 
reportedly refused use of a ventilator or BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).