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

We decided that the Plan does not have to pay for a lumbar sacral orthosis (HCPCS L0631) provided to the 
enrollee on January 28, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code L0631 (1 Unit) remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that DME supplies must be 
provided with a proof of delivery and a valid physician order. 
 
In this case, the CPT Code Manual definition of HCPCS code L0631 is "Lumbar-sacral orthosis, sagittal 
control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 
vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, 
may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, 
bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise." 
 
We find that HCPCS code L0631 is not supported in the medical record. Specifically, there is no valid 
physician order or proof of delivery for this item. 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 a 
lumbar sacral orthosis (HCPCS L0631) provided to the enrollee on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar epidural steroid injections to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the requesting provider is the only one who has 
been able to treat the enrollee. The Plan denied your request. The Plan says there are network providers 
available and accessible that can treat the enrollee. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
lumbar epidural steroid injections to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP device for 12 months.

You asked the Plan to pre-approve a CPAP device 12 months. You say that you have difficulty sleeping and lost your CPAP device. The Plan denied your request. The Plan says they will only approve 3 months and then reevaluate for compliance.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP device for an additional 9 months have not been met. Therefore, we decided that the Plan does not have to pre-approve a CPAP device for the additional 9 months.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, and batteries provided on May 28, 2020.

You asked the Plan to pay for the test strips, lancets, and batteries. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the billed services are not supported.

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 physician order or proof of delivery. The physician order is dated after the date of service and is incomplete. The Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket. 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 test strips, lancets, and batteries provided on May 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Sphygmomanometer/blood pressure apparatus with cuff and stethoscope.

You asked the Plan to provide Sphygmomanometer/blood pressure apparatus with cuff and stethoscope. You say that you need to monitor your blood pressure at home. The Plan denied your request. The Plan says you are not receiving dialysis at home therefore the blood pressure monitor is denied.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. 

The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to provide a Sphygmomanometer/blood pressure apparatus with cuff and stethoscope.
Appeal type: Inpatient Hospital
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare will pay for an IRF admission when the services are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week. The patient does not need to be expected to achieve complete independence in self-care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. You can find these rules in the Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy services (97124).

You asked the Plan to pre-approve massage therapy services. You say that the massage therapy is medically necessary due to chronic pain. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy services (97124).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a laminotomy (63030, 63035) provided on December 30, 2019.

You asked the Plan to pay for a laminotomy. You say that this should be covered. The Plan denied your request. The Plan says CPT 63048 would be more appropriate.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 63030 is laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar, and 63035 is laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure).

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 a laminotomy. Our reviewer says that these codes are not supported. Our physician reviewer found the operative report documents that decompression of the spinal cord was performed, therefore CPT 63030 and CPT 63035 cannot be verified.

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 laminotomy have not been met. Therefore, we decided that the Plan does not have to pay for a laminotomy (63030, 63035) provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and treatment to be provided by out of network providers.

You asked the Plan to pre-approve a consultation and treatment. You say that you have family in Miami and the requested physician is able to do a minimally invasive procedure. The Plan denied your request. The Plan says the services are available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a consultation and treatment to be provided by out of network providers.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on May 18, 2020. You asked the Plan to pay for the physician services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says Original Medicare is responsible for coverage of the Part B benefits. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the physician services provided on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says only 1 
medial branch block has been performed. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered under certain 
medical indications. 
 
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 services. Our physician 
reviewer found that the enrollee has chronic low back pain. On magnetic resonance imaging (MRI), he has 
facet arthropathy. He had a diagnostic set of MBBs and achieved 70-80% pain relief. The requirement is for 
dual diagnostic blocks. The enrollee only had one. Therefore, the requested procedure is not medically 
reasonable or necessary at this time. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that prior authorization was not obtained. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee. 
  
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 infusion services provided from January 29, 2020, through 
February 5, 2020. 
 
You asked the Plan to pay for the infusion services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for infusion services provided from January 29, 2020, through 
February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the parenteral nutrition provided to the enrollee from November 11,
2019, through November 17, 2019.
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan
denied your request. The Plan says that that this service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that parenteral nutrition is covered for the above
criteria.
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
requested items/services are considered medically reasonable and necessary in this case. The documentation
supports that the enrollee's overall health status requires intravenous nutrition and it is not possible utilizing all
of the following approaches: modifying the nutrient composition of the enteral diet (e.g., lactose free, gluten
free, low in long chain triglycerides, substitution with medium chain triglycerides, provision of protein as
peptides or amino acids, etc.), and utilizing pharmacologic means to treat the etiology of the malabsorption
(e.g., pancreatic enzymes or bile salts, broad spectrum antibiotics for bacterial overgrowth, prokinetic
medication for reduced motility, etc.). Our physician reviewer found that the enrollee's condition met Medicare
criteria for these services.
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 been met. Therefore, we decided that the Plan has to pay for
the parenteral nutrition provided to the enrollee from November 11, 2019, through November 17, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing rendered on March 4, 2020. 
 
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 testing was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that drug testing 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 
testing was not medically necessary. Our physician reviewer found the submitted documentation does not 
outline a rationale for testing all the drugs in the requested comprehensive panel. Additionally, clinical 
decision-making guided by the test results was not discussed. Without the support of the records, the testing is 
not considered 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 definitive drug testing rendered on March 4, 2020.  
 
The Local Coverage Determination (LCD) referenced by the Plan was for the wrong jurisdiction and not used 
in the determination.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from May 23, 2020, 
to May 24, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee from May 23, 2020, to May 24, 2020. 
  
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 genetic testing provided by an out 
of network (OON) provider. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization and the ordering physician was not in 
network. 
 
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 in this case is not a network provider with the Plan. 
The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not 
pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided by an out of network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAranesp (J0881).You asked the Plan to pre-approveAranesp. You say that you would like reconsideration because this drug is medically necessary.The Plan denied your request. The Plan says off-label use of this drug for the member's condition is not medically accepted per Medicare rules and isn't covered based on available information.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aranesp. Our reviewer says that the requested use of this drug is not FDA approved for the member's diagnosis. Our physician reviewer found the requested use of this drug is also not supported by one of the major drug compendia. Due to the member's iron saturation, iron supplementation should take place prior to Aranesp.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approveAranesp (J0881).