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

 
We decided that the Plan does not have to pre-approve a pressure-reducing mattress. You asked the Plan to pre-approve the requested mattress. You say that the mattress will prevent the ulcer from 
worsening. The Plan denied your request. The Plan says coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that pressure reducing support surfaces are only 
covered under certain medical indications.  
 
We looked at the file and Medicare rules. The file does not show that you have multiple stage 2 ulcers, a large 
or multiple stage 3-4 ulcers, or have had a myocutaneous flap for an ulcer within the past 60 days. Based on 
this information, we decided that Medicare rules for coverage of the requested mattress have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a pressure-reducing mattress.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission stay provided on August 07, 2023, to 
August 12, 2023. 
 
You asked the Plan to pay for inpatient admission stay. You say that the services were medically necessary. 
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 inpatient admission stay 
provided on August 07, 2023, to August 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on June 28, 2023, and July 
3, 2023, by an OON provider.  
 
You asked the Plan to pay for the chiropractic services. You say that the provider is in-network, and the claim 
should be reprocessed for payment. The Plan denied your request. The Plan says these services are not covered 
when received by an out-of-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 will cover services from either network or out-of-network providers if the services are 
covered benefits and are medically necessary. The Plan contract also says that out-of-network routine 
chiropractic care under the POS benefit is not covered. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 chiropractic services provided on June 28, 2023, and July 
3, 2023, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
September 20, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that you disagree with 
the copayment. 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 $55 
copayment for outpatient diagnostic tests/Medicare-coveredstandard x-ray and ultrasound. 
 
You have been asked to pay a $55 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic tests/Medicare-coveredstandard x-ray and ultrasound 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. However, since the allowed amount is 
less than the standard copayment, you only owe $39.15. Therefore, we decided that the Plan does not have to 
waive the copayment for an outpatient diagnostic test provided on September 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from March 31, 2023, to  
April 22, 2023.  
 
You asked the Plan to pay for the physician's services. You say that you have been trying to get these claims 
submitted to your primary insurer and you would like the Plan to either cover these dates of service or allow 
more time until the provider submits the claims to your primary insurer. The Plan denied your request. The 
Plan says for a paper claim to be considered for benefits, a copy of the primary payer's explanation of benefits 
(EOB) notice must be forwarded along with the claim form. Review of the members claim history showed that 
a primary payer EOB was not locate 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made 
multiple attempts to the member to obtain the primary insurer EOB. As the secondary insurer, the Plan cannot 
be held responsible for the physician's services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for physician's services provided from 
March 31, 2023, to April 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that you would like this item due to having 
double amputated legs and would not be able to get out of home if there was a fire. The Plan denied your 
request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair ramp.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagastroduodenoscopy (EGD). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the next EGD for surveillance should be 2027. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that for short segment Barrett's esophagus, as present in this case, the appropriate surveillance interval is 
5 years as 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an esophagastroduodenoscopy (EGD).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 17, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the 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 laboratory services 
provided on July 17, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy guidelines were not followed. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that there is no 
indication the member has had an osteoporosis-related fracture. The enrollee has not tried and failed zoledronic 
acid. There is no indication zoledronic acid, an IV bisphosphonate drug, would likely be less effective, and/or 
cause 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal genetic testing (81479) provided on March 
3, 2023. 
 
You asked the Plan to pay for a Guardant Reveal test. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says this molecular pathology testing is not a covered 
benefit. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the DEXTM Diagnostics Exchange shows that the test at 
issue is not covered under the MolDX program. Based on this information, we decided that Medicare rules for 
coverage of a Guardant Reveal test have not been met. Therefore, we decided that the Plan does not have to 
pay for Guardant Reveal genetic testing (81479) provided on March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4239 billed for date of service July 1, 2023.  
You asked the Plan to pay for code A4239. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says code A4239 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 code. 
 
We find that procedure code A4239 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4239 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of code A4239 have not been met. Therefore, we decided that the Plan does not have to pay for code 
A4239 billed for date of service July 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 21, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. 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 $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on May 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 28, 2022, to 
May 30, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code E87.2, described as 
acidosis. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare 
rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the 
DRG originally billed. Our reviewer says that documentation does not support the billed code. Our physician 
reviewer found that the enrollee is a 73-year-old male who was treated in the hospital for a lower 
gastrointestinal bleed and was diagnosed with residual hemorrhoidal skin tags. Workup and monitoring 
described the enrollee with bicarb level of 24, anion gap of 11, and lactic acid 2.1, but no arterial blood gas 
results were given. He was treated with fluids and lactic acid reduced to 1.8 shortly afterward. He did not have 
acidosis following initial fluid administration. As such, the code E87.2 is not sufficiently supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 28, 2022, to May 30, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an ILR. 
 You asked the Plan to pre-approve the requested ILR procedure. You say that the enrollee had a massive 
cryptogenic cerebral vascular accident (CVA) and a negative 1-month long-term monitor. You say that the 
enrollee needs a loop for a more long-term heart monitoring. You say that the loop recorder is a good measure 
to make sure no arrhythmia's contributed to the massive stroke. The Plan denied your request. The Plan says 
placement of an ILR is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found that the enrollee had a stroke. However, this is no history of atrial 
fibrillation, or any significant cardiac arrhythmias noted on electrocardiogram (ECG) monitoring. Therefore, an 
insertion of an ILR would not be considered medically appropriate and necessary in the enrollee's 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 the requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an ILR.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an ILR. 
 You asked the Plan to pre-approve the requested ILR procedure. You say that the enrollee needs long term 
monitoring for atrial arrhythmia given recent cerebral vascular accident (CVA). The Plan denied your request. 
The Plan says that insertion and programming of subcutaneous cardiac rhythm monitor is not medically 
necessary.  
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found that while the enrollee has a history of atrial fibrillation and strokes, 
there is no documentation provided to suggest a history of unexplained syncope or any other apparent 
indication for an ILR. There is insufficient documentation to support the medical necessity for insertion of an 
ILR in the enrollee's 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 the requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an ILR.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a two-level percutaneous vertebroplasty. 
 
You asked the Plan to pre-approve a two-level percutaneous vertebroplasty. The Plan denied your request. The 
Plan says a two-level percutaneous vertebroplasty is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a two-level percutaneous 
vertebroplasty. Our reviewer says that a two-level percutaneous vertebroplasty is not medically necessary. Our 
physician reviewer found the documentation is not evident regarding an acute or subacute compression failure. 
Additionally, there is no documentation of a progression of the body height loss, greater than 25% vertebral 
body height loss, kyphotic deformity, or a severe impact on daily activities. However, there is computed 
tomography corroboration of retropulsion and other plausible causes of pain. Therefore, the enrollee does not 
meet the LCD coverage criteria. 
 
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 two-level percutaneous vertebroplasty. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a two-level percutaneous vertebroplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 05, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on July 05, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trazimera infusions. 
 
You asked the Plan to pre-approve the infusions. You say that this is medically necessary. The Plan denied 
your request. The Plan says coverage cannot be provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the infusions. Our reviewer says that 
the requested services are not medically reasonable or necessary. Our physician reviewer found that the 
enrollee has a cT2N2M0 esophageal cancer for whom treatment with Trazimera to be used in combination with 
Pembrolizumab is requested. The enrollee was diagnosed in June 2023, and received chemoradiation with partial response on positron emission tomography/computed tomography (PET/CT) on October 25, 2023. The 
tumor is PDL1 CPS more than 10, and HER2 positive. Due to comorbidities, the enrollee is not a surgical or 
chemotherapy candidate. The requested use of Trazimera is not Food and Drug Administration (FDA) 
approved for the enrollee's diagnosis, as the enrollee is not metastatic. The use of this drug is not supported by 
one of the major drug compendia, or by clinical research that appears in a Medicare-approved compendia or 
medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the infusions have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Trazimera infusions.