Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient injection of Pembrolizumab 1mg (J9271). 
 
You asked the Plan to pre-approve an injection. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the requested injection is requested to treat the enrollee's cancer of the vulva that 
has spread to other organs. The enrollee does not meet criteria for coverage of the requested injection. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of vulvar cancer. The medications are requested to treat cancer of the 
vulva that has spread to other organs. Information provided indicates that Keytruda and Fulphila will be 
combined with other medications commonly used to treat this condition. Keytruda can only be approved when 
there is enough published evidence to show that this medication is safe and helpful for the enrollee's condition. 
There is not enough evidence to show that Keytruda is safe and helpful for the treatment of cancer of the vulva. 
The enrollee does not meet criteria for approval of the requested injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an outpatient injection of Pembrolizumab 1mg (J9271).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer.

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 step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia. He has not tried and failed the Plan's required drugs, Infed and Venofer. The records do not show that the required drugs would be contraindicated or less effective; therefore, Injectafer is 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 Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (64634) provided on October 25, 2022. 
 
You asked the Plan to pay for the injections. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code billed is 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 CPT code. 
 
We find that CPT code 64634 is not supported in the medical record. Specifically, this code has a status of "N" 
and is a packaged service. The code is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pay for injections (64634) provided on October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third level facet joint injection and conscious sedation. 
 
You asked the Plan to pre-approve a third level facet joint injection and conscious sedation. You say that three 
levels of facet joint injections and conscious sedation are medically necessary. The Plan denied your request. 
The Plan says a third level facet joint injection and conscious sedation are not medically necessary and do not 
meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 third level facet joint injection and 
conscious sedation. Our reviewer says that a third level facet joint injection and conscious sedation are not 
considered medically necessary. Our physician reviewer found that the Medicare LCD limits to two levels the 
number of diagnostic blocks. So only two are deemed medically reasonable and necessary. Additionally, there 
is no indication clearly documented for sedation. Therefore, a third level facet joint injection and sedation is 
deemed not medically reasonable and 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 third level facet joint injection and conscious sedation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a third level facet joint injection and 
conscious sedation.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 28, 2022, to 
June 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted timely. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 28, 2022, to June 
26, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services provided on December 12, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the provider is not eligible to bill 
Medicare. 
 
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. In this case, the Plan has provided no evidence that shows the provider is 
ineligible to bill Medicare. Therefore, we decided that the Plan has to pay for the emergency room services 
provided on December 12, 2022.  
 
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 pay for ambulance services billed for date of service March 5, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the services at issue have been billed correctly. 
The Plan denied your request. The Plan says that this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
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 documentation indicating that the 
ambulance services provided on March 5, 2022, have been previously paid. It is the Plan's responsibility to 
support its denial with evidence. In this case, the Plan's denial is not supported, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for ambulance services billed for date of service March 5, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 10, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided on 
December 2, 2022. We also decided that the Plan does not have to pay for surgical placement of implant body: 
endosteal implant (D6010), custom fabricated abutment  includes placement (D6057), and bone graft at time 
of implant placement (D6104) provided on December 2, 2022. 
 
You asked the Plan to waive the coinsurance for erupted tooth requiring removal of bone and/or sectioning of 
tooth (D7210). You say that the reimbursement is incorrect and you are due a greater amount than you 
received. The Plan denied your request. The Plan says the coinsurance was appropriately applied to the erupted 
tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if 
indicated (D7210). The Plan says the dental codes represented by D6010, D6057 and D6104 are not covered 
under your dental benefits. 
 
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 50% 
coinsurance for extractions and oral surgery procedures. 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. 
 
You have been asked to pay a 50% coinsurance for the erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210). This service falls within the extractions and oral surgery procedures 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 erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided on 
December 2, 2022. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage the dental codes represented by D6010, 
D6057 and D6104 are not among those covered this benefit. Therefore, we decided that the Plan does not have 
to pay for the surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment  
includes placement (D6057), and bone graft at time of implant placement (D6104) provided on December 2, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 96372 billed for date of service November 26, 2022. 
 
You asked the Plan to pay for code 96372. You say that this is a covered code and was medically necessary. 
The Plan denied your request. The Plan says this code is not separately payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV-
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. 
 In this case, code 96372 is a STV-packaged service because it is assigned a status indicator of Q1. This code 
was billed on the same claim with code 99285, which has a status indicator of V.  As a result, the STV-
packaged service (i.e., 96372) is not separately payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 96372 have not been met. Therefore, we decided that the Plan does not have to pay for code 
96372 billed for date of service November 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377, E2300). 
 
You asked the Plan to pre-approve additional power wheelchair accessories. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that services are covered if they are medically necessary. 
Medicare rules say that a power seat elevation feature (E2300) is not covered because it is not primarily 
medical in nature. 
 
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 additional power wheelchair 
accessories. Our reviewer says that the requested items are not medically necessary. Our physician reviewer 
found while the expandable controller is allowed it is not medically necessary as it is not necessary for the 
enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional power wheelchair accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, 
E2377, E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary & mandibular (D5110, 
D5120). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 23, 2021. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary & mandibular 
(D5110, D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of intra-socket biological dressing (D7922) 
and a hospital call (D9420) for tooth #29 provided on November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services were medically necessary 
prior to your surgery. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the placement of intra-socket biological dressing and the hospital call are not covered by the 
Plan. 
 
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 pay for the 
placement of intra-socket biological dressing (D7922) and a hospital call (D9420) for tooth #29 provided on 
November 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 You asked the Plan to pre-approve Ilumya. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says a trial of adalimumab, Rinvoq, Skyrizi, Actemra, Cosentyx, Otezla, Xeljanz, Xeljanz 
XR, Orencia or Enbrel is required before alternatives can be considered. 
 
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 Ilumya. Our reviewer says that Ilumya 
is not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drugs, 
or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Dental Savers Program provided from May 23, 2022, to 
December 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider is in-network with the Plan. The 
Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pay for the Dental 
Savers Program provided from May 23, 2022, to December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system, axial ankle with swing phase, and 
vertical shock reducing pylon. 
 
You asked the Plan to pre-approve a vertical shock reducing pylon. You say that these components are the only 
ones that will enable the enrollee to move forward with safety and stability for their age. You say that the 
enrollee does not meet the criteria for a lesser foot. The Plan denied your request. The Plan says the 
documentation does not support the need for an upgraded pylon. 
 
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 vertical shock reducing pylon. Our reviewer says that the requested vertical shock reducing pylon is not medically necessary. Our physician 
reviewer found the documentation does not support the need for an upgraded pylon. Therefore, the reviewer 
found that the requested vertical shock reducing pylon 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 vertical shock reducing pylon have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a flex-walk system, axial ankle with swing phase, and vertical shock 
reducing pylon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoll Lifevest automatic external defibrillator (AED) 
rendered on November 5, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an automatic external defibrillator (AED) is 
covered when specific 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has dilated cardiomyopathy. 
The records do not support that the enrollee has a diagnosis or condition listed in the Medicare rules as a 
covered condition for the AED. The services were 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 pay for the Zoll Lifevest automatic external defibrillator (AED) rendered on November 5, 2022.