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

 
We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided to the enrollee 
on August 10, 2020. 
 
You asked the Plan to pay for the stimulator. You say that this should be paid for. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriatecode. 
 
In this case, the CPT Code Manual definition of HCPCS code E0745 is "Neuromuscular stimulator, electronic 
shock unit." 
 
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 stimulator. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
documentation includes a physician order for equipment, however, no proof of delivery was included to 
confirm medical equipment was delivered to the enrollee. Therefore, this service cannot be verified as 
performed. 
 
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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pay for a neuromuscular stimulator (E0745) provided to the enrollee on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthoses (L1851 and L2397) provided on June 26, 
2020. 
 
You asked the Plan to pay for the knee orthoses. You say that you would like reconsideration because these 
orthoses are medically necessary. The Plan denied your request. The Plan says this claim is a result of 
telemarketing to a Medicare beneficiary and is not reimbursable. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record does not 
include a proof of delivery or any delivery information for the billed supplies. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the knee orthoses (L1851 and L2397) provided on June 26, 2020.
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's co morbid conditions, 
history of present illness, and clinical needs make an LTACH admission vital. The Plan denied your request. 
The Plan says the guidelines for coverage have not been met. The Plan says that the services needed could be 
provided in another setting. 
 
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 is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 17, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
member's primary care physician did not refer these services. The Plan says that there is no referring provider.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
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 physician services provided on September 17, 
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (HCPCS S9999) provided to the 
enrollee on April 27, 2020. 
 
You asked the Plan to pay for the DME. You say that this should be paid for. The Plan denied your request. 
The Plan says this is an invalid procedure code for this service. 
 
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 HCPCS code S9999 is not supported in the medical record. Specifically, this code has a status 
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for 
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the DME have 
not been met. Therefore, we decided that the Plan does not have to pay for durable medical equipment (HCPCS 
S9999) provided to the enrollee on April 27, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a 
hip fracture after a fall. The enrollee's medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite - three surfaces, posterior (D2393) 
provided on September 24, 2020. 
 
You asked the Plan to pay for resin-based composite. You say that the services should be covered. The Plan 
denied your request. The Plan says the plan maximum for supplemental dental benefits has been exhausted for 
the plan year. 
 
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. Specifically, records indicated you had already utilized the entire $500 
allowance for the plan year. You are responsible for any cost over the allowance. Therefore, we decided that 
the Plan does not have to pay for resin-based composite - three surfaces, posterior (D2393) provided on 
September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair (K0861). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you require the power wheelchair. You 
have purchased a scooter in the past but had difficult using it. Your doctor has noted impaired vision. The Plan 
denied your request. The Plan says the documentation does not show you can safely utilize the power 
wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you cannot safely operate the PMD being requested. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
power wheelchair (K0861).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PETCT (78815-26PS) provided on August 28, 2020. 
 
You asked the Plan to pay for the PETCT. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says an appropriate diagnosis code was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 78815-26PS is not supported in the medical record. Specifically, Per chapter 13 of the 
Medicare Claims Processing Manual, the billed diagnosis codes are not listed as appropriate for the service 
billed. Based on this information, we decided that Medicare rules for coverage of the PETCT have not been 
met. Therefore, we decided that the Plan does not have to pay for PETCT (78815-26PS) provided on August 
28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the care could be received in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture after a fall. Medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Entyvio every four weeks. 
 
You asked the Plan to pre-approve Entyvio every four weeks. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the requested drug is not medically 
necessary at the requested dosage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Entyvio every four weeks. Our 
reviewer says that the documentation supports that the requested drug with the requested dosage frequency is 
medically reasonable and necessary. Our physician reviewer found the enrollee has a history of Crohn's disease 
and has been treated with Entyvio since February 2018. Vedolizumab (Entyvio, Takeda) works by interfering 
with lymphocyte trafficking in the gastrointestinal tract. Specifically, it binds to the a4?7 integrin, which is a 
protein on the surface of lymphocytes targeted for the gastrointestinal tract. Thus, vedolizumab does not allow 
lymphocytes expressing a4?7 to connect with mucosal vascular address in cell adhesion molecules, which are 
expressed on the gastrointestinal epithelium. This disruption reduces inflammation in the gastrointestinal tract. 
While Entyvio is FDA approved for dosing at a Q8week interval, doses given more frequently are considered 
excessive under the Medicare guidelines. The review indicates that the enrollee's Gastroenterology provider has 
supplied data on increasing the Entyvio interval to four weeks with positive results. The review has determined 
that the documentation supports that the requested Entyvio at four-week intervals is medically reasonable and 
necessary for the enrollee. The documentation supports that Entyvio at four-week intervals is safe and effective 
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 Entyvio every four weeks have been met. Therefore, we decided that the Plan 
has to pre-approve Entyvio every four weeks.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dentures (D5110) provided on July 28, 2020. 
 
You asked the Plan to pay for dentures. You say that this should be covered. The Plan denied your request. The 
Plan says this exceeds the quarterly allowance. 
 
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, it covers only up to $600 of 
comprehensive dental services. The record shows that this maximum allowance was met for the quarter in 
which the dentures at issue were provided. Therefore, we decided that the Plan does not have to pay for 
dentures (D5110) provided on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral drugs, gingival irrigation, medication delivery, and 
pre-diagnostic testing provided to you on August 17, 2020. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services 
are not a covered benefit. 
 
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 services are not among 
those covered under this benefit. The Plans covers only those dental services listed in the Evidence of 
Coverage. Oral drugs, gingival irrigation, medication delivery, and pre-diagnostic testing are not covered. 
Therefore, we decided that the Plan does not have to pay for the oral drugs, gingival irrigation, medication 
delivery, and pre-diagnostic testing provided to you on August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses (L2397, L1833) provided May 27, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
The record reveals no physical exam or any attempt by the telehealth provider to contact the enrollee's local 
physician. This means that the telehealth visit is not a covered service under the Medicare program and cannot 
substitute for an in-person encounter. 
 
 
 
 
 
 
 
 
 Consequently, the items ordered following the noncovered visit are likewise non-covered. Therefore, we 
decided that the Plan does not have to pay for orthoses (L2397, L1833) provided May 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nivolumab. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has stage III non-small cell 
lung cancer (NSCLC) and poor performance status. Guidelines for first line treatment of NSCLC in patients 
with poor performance status do not support the use of nivolumab. The drug is not FDA approved for this 
scenario or supported by major drug compendia or the medical literature. The service 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 nivolumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on August 3, 2020, to August 
5, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that you were unaware that you needed prior 
authorization for these services. The Plan denied your request. The Plan says prior authorization was not 
obtained. The Plan says that there are in-network providers available for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
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 chiropractic services provided on August 3, 2020, 
to August 5, 2020 by an out of network (OON) provider.