Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the medical records
from the ordering provider do not document the treating physician had intended the clinical diagnostic test be
performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. 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 pay for the
drug testing services provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627).
You asked the Plan to pre-approve a seat lift mechanism. You say that you have hip and leg problems and are
constantly in pain. The Plan denied your request. The Plan says that you do not meet Medicare criteria for
coverage of a seat lift mechanism.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above are met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the seat lift mechanism. Our reviewer
says that you do not meet criteria for coverage of a seat lift mechanism. Our physician reviewer found the
record indicates that your physician classified your arthritis as moderate with no neuromuscular disease. The
physician's documentation did not indicate that a seat lift mechanism is part of the practitioner's course of
treatment and prescribed to improve, or stop deterioration of, your condition. Additionally, the record states
that your physician classified your mobility as normal and did not indicate that you are completely incapable of
standing from a chair in your home.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this seat lift mechanism have not been met. Therefore, we decided that the Plan
does not have to pre-approve a seat lift mechanism (E0627).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit and radiology services provided on December 30, 2019.
You asked the Plan to pay for the office visit and radiology procedures. You say that the provider's credentials have been provided to show that he is eligible to provide these services. The Plan denied your request. The Plan says that the provider is no longer credentialed or eligible for Medicare/Medicaid billing of services.
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. The documentation provided in the case file does not support that the treating physician had an inactive license on the date of service in question. Review of the Missouri Division of Professional Registration website, the provider at issue in this case has an active Missouri medical license. No other documentation was submitted to support that the provider is prohibited from billing Medicare or Medicare health plans for services rendered. As such, the Plan's denial is not substantiated in this case. Therefore, we decided that the Plan has to pay for the office visit and radiology services provided on December 30, 2019.
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit provided on November 25, 2019.
You asked the Plan to pay for the office visit. You say that the provider's credentials have been provided to show that he is eligible to provide these services. The Plan denied your request. The Plan says that the provider is no longer credentialed or eligible for Medicare/Medicaid billing of services.
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. The documentation provided in the case file does not support that the treating physician had an inactive license on the date of service in question. Review of the Missouri Division of Professional Registration website, the provider at issue in this case has an active Missouri medical license. No other documentation was submitted to support that the provider is prohibited from billing Medicare or Medicare health plans for services rendered. As such, the Plan's denial is not substantiated in this case. Therefore, we decided that the Plan has to pay for the office visit provided on November 25, 2019.
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 Flexitouch pneumatic compression device (E0652)
and sleeve (E0667) for the enrollee..
You asked the Plan to pre-approve a pneumatic compression device and sleeve. You say that this is medically
necessary. The Plan denied your request. The Plan says that there has been no documented trial of conservative
therapy demonstrating failed response to treatment with a E0650 or E0651 for 4 weeks.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic
compression device (E0652) and sleeve (E0667) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 100% cotton bedding sheets, pillowcases and pillows
(E1399).
You asked the Plan to pre-approve the bedding. You say that due to your medical condition you need organic
bedding because you have severe allergies. The Plan denied your request. The Plan says this is not a covered
benefit under Medicare or the plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve 100% cotton bedding sheets, pillowcases and pillows
(E1399).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve positive airway pressure chinstrap (A7036) positive airway
pressure tubing (A7037) filter (A7039) replacement water chamber A7046) replacement oral cushion for
combination oral/nasal mask (A7028) replacement face mask interface (A7031) replacement nasal cushion
(A7032).
You asked the Plan to pre-approve the CPAP supplies. You say that you were unable to use the CPAP due to
there being no distilled water in the stores due to COVID. The Plan denied your request. The Plan says that the
enrollee did not meet the minimum compliance criteria of at least 4 hrs/night for at least 70% of nights.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 the CPAP supplies. Our reviewer says
that the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found this enrollee is on CPAP for obstructive sleep apnea. CPAP supplies have been denied because
the enrollee did not meet the minimum compliance criteria of at least 4 hrs/night for at least 70% of nights. The
appeal indicates the enrollee was unable to obtain distilled water during this time because of the pandemic. The
enrollee should be provided with coverage of CPAP and necessary supplies for an additional 3 months.
Compliance should be reassessed during this time. If the enrollee is unable to meet the minimum usage criteria
then CPAP would be deemed not 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 the CPAP supplies have been met. Therefore, we decided that the Plan has to
pre-approve positive airway pressure chinstrap (A7036) positive airway pressure tubing (A7037) filter (A7039)
replacement water chamber A7046) replacement oral cushion for combination oral/nasal mask (A7028)
replacement face mask interface (A7031) replacement nasal cushion (A7032).
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the administration of chemotherapy provided on September
25, 2019.
You asked the Plan to pay for the administration of chemotherapy. You say that the Plan cannot require preapproval
for services related to clinical trials. You say that the Plan stated that you are covered for routine
items and services you receive as part of the study. The Plan denied your request. The Plan says routine costs
associated with your clinical trial should be billed to Original Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pay for the administration of chemotherapy as part of a clinical trial. The
Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan
does not have to pay for the administration of chemotherapy provided on September 25, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a retrobulbar injection (67500) provided on November 12, 2019.
You asked the Plan to pay for the retrobulbar injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that payment is not allowed because this claim contains non-anesthesia services submitted by an anesthesiologist.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of 67500 have been met. Specifically, this service was provided by a provider different than that of the anesthesia procedure. The Medicare rules referenced by the Plan do not state that the provider type at issue cannot bill for code 67500. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for a retrobulbar injection (67500) provided on November 12, 2019.
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: Favorable

We decided that the Plan has to pay for the office visit and presumptive drug screen provided on August 12, 2019.
You asked the Plan to pay for the office visit and drug screen. You say that the provider's credentials have been provided to show that he is eligible to provide these services. The Plan denied your request. The Plan says that the provider is no longer credentialed or eligible for Medicare/Medicaid billing of services.
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. The documentation provided in the case file does not support that the treating physician had an inactive license on the date of service in question. Review of the Missouri Division of Professional Registration website, the provider at issue in this case has an active Missouri medical license. No other documentation was submitted to support that the provider is prohibited from billing Medicare or Medicare health plans for services rendered. As such, the Plan's denial is not substantiated in this case. Therefore, we decided that the Plan has to pay for the office visit and presumptive drug screen provided on August 12, 2019.
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 services (CPT 88360) provided on June 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not
payable.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair,
the column two code is denied, and the column one code is eligible for payment. Procedure code 88360 is part
of an edit pair with procedure code 88323. Procedure code 88323 is a column one code, and procedure code
88360 is a column two code. Procedure code 88323 has been paid for this date of service, which means that
procedure code 88360 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for
the services (CPT 88360) provided on June 26, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat Zilretta injections (J3304).
You asked the Plan to pre-approve the injections. You say that you would like reconsideration because this
drug is medically necessary. The Plan denied your request. The Plan says repeat use of Zilretta is not FDA
approved.
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 the injections. Our reviewer says that
the efficacy and safety of repeat administration of Zilretta has not been demonstrated. Our physician reviewer
found this drug is not medically reasonable and necessary for the member.
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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve repeat Zilretta injections (J3304).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear purchased on December 30, 2019 from an out-ofnetwork
eyewear supplier.
You asked the Plan to pay for the eyewear. You say that you are requesting reimbursement of services
rendered. The Plan denied your request. The Plan says you are requesting reimbursement of services rendered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.
We looked at the file and the Plan's rules. Review of the file show that you purchased eyewear on December
30, 2019 from an out-of-network eyewear supplier. The Plan reimbursed you the $50 for the eyewear. Your
EOC states, enrollees must pay a $30 copayment for each out-of-network routine eye exam per year.
Reimbursed up to $50 for one (1) pair of eyeglasses every year (with single-vision, lined bifocal, trifocal or
lenticular lenses only) or 1 pair of contact lenses. Therefore, we decided that the Plan does not have to pay for
eyewear purchased on December 30, 2019 from an out-of-network eyewear supplier.
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 a long term acute care hospital admission
is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of a
long term acute care hospital admission.
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 that you are currently undergoing treatment at an acute care hospital (ACH) for a
chronic sacral wound. There is no evidence that you require services that are not currently available. As
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to
the LTACH. You can remain at the current acute care hospital until such time no acute services are required.
You can then be transferred/discharged to a lower level of care for any ongoing long term care 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee did not require skilled nursing
services to safely and effectively provide medically necessary and reasonable treatment. The enrollee's
functional level does not require skilled therapy services to safely and effectively provide medically necessary
and reasonable treatment only in a SNF. It is not medically reasonable and necessary to provide skilled nursing
or skilled therapy services (or a combination of these services) on a "daily basis." As a practical matter this
enrollee did not require the necessary services on an inpatient basis, in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional acupuncture services.
You asked the Plan to pre-approve acupuncture services. The Plan denied your request.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.
The file shows that 8 acupuncture visits were requested. The Plan has agreed to pre-approve 5 visits. We
looked at the file and Medicare rules. The records provided show that you have neck pain. Medicare offers
limited coverage of acupuncture treatments for chronic low back pain. Based on this information, we decided
that the rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve
additional acupuncture services.