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 July 27, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 July 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda solution 100mg/4ml for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a requirement that the cancer did not improve after receiving systemic therapy. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee is a 76 year 
old female with endometrial cancer status post surgical resection in 2017. In July 2020, debulking surgery 
revealed recurrence, and she was treated with radiation therapy. PET scan was scheduled in January 2021 
which resulted in lung nodules observed, suggesting metastatic endometrial cancer. Keytruda was requested. 
The records did not show evidence of the enrollee having tried and failed chemotherapy or had any specific 
contraindication to such which according to the NCCN guidelines is first line therapy prior to considering 
pembrolizumab on its own. The records do not show the enrollee participating in a trial. Therefore, without 
sufficient support made for this request, the Keytruda will be considered not medically 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda solution 100mg/4ml for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 17, 2020. 
 
You asked the Plan to pay for the services. 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 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-
network provider on August 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health physical therapy services provided from 
February 15, 2020, to March 13, 2020, billed with code S9131. 
 
You asked the Plan to pay for the home health services as billed. You say that this was billed correctly and 
should be paid in full. The Plan denied your request. The Plan says this home health claim is not billed with 
valid codes. 
 
The Plan must follow Medicare rules. Medicare rules say that to report home health physical therapy services, 
providers must use codes G0151, G0157, G0159, or G2168 as appropriate.  
 
The code S9131 is not valid for Medicare billing of home health services. Therefore, we decided that the Plan 
does not have to pay for the home health physical therapy services provided from February 15, 2020, to March 
13, 2020, billed with code S9131.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Forteo. 
 
You asked the Plan to pre-approve Forteo. You say that the enrollee is high risk for fractures. The Plan denied 
your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Forteo.  
 
Benefits for Forteo may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
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. 
 
You asked the Plan to pre-approve IRF care. You say that you feel that because of your Parkinson's disease, 
you need more intensive therapy from a facility that specializes in care for those with the condition. The Plan 
denied your request. The Plan says this level of care is not needed. 
 
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 patient was admitted for surgical repair of a femur 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 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. 
 
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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from August 1, 2019, to August 31, 
2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
Medicare eligible. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the services provided from August 1, 
2019, to August 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy. 
 
You asked the Plan to pre-approve varicose veins Surgery 36478. You say that this is medically necessary. The Plan denied your request. The Plan says there has 
not been any weight reduction and compression stockings usage has only been as needed. 
 
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 varicose veins Surgery 36478. Our reviewer says that the requested services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the documentation does not 
meet policy coverage criteria and does not support the medical necessity of the procedure in question. The 
enrollee has numerous coexisting factors that could contribute to leg pain including a history of osteoarthritis 
and morbid obesity. She complains of a stabbing pain in the hip which is unlikely to resolve with accessory 
saphenous vein ablation. Specifically, she does not meet criteria for efforts at conservative treatment such as 
weight reduction and regular use of compression stockings. Additionally there is no clear documentation that 
the patient is currently having activity limiting symptoms attributable to the varicose veins. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of varicose veins Surgery 36478 have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on April 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no evidence of 
a relationship with the ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
services provided on April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S9501, S9502) provided from April 29, 2020, to 
May 5, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Codes S9501 and S9502 are assigned a status indicator of ?I? under 
the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, these services. 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 services (S9501, S9502) provided from April 29, 2020, to May 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that you believe that the SNF level of care is 
medically necessary. The Plan denied your request. The Plan says the enrollee's needs are mostly custodial at 
this time. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 84-year-old 
female with acute kidney injury, seizure disorder, altered mental status, and visual hallucinations. From a 
nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. Her lungs 
were clear. She was treated with IV fluids. Regarding rehabilitation services, the beneficiary received PT and 
OT in the acute hospital.  The beneficiary was at a minimal to maximal assist level with functional 
mobility. The beneficiary required varying assist with ADLs. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, these do not require daily skilled therapy services. This beneficiary does not meet severity of illness 
or intensity of service criteria for 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine you received on October 23, 2020. 
 
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the Tdap vaccine you received on October 23, 
2020.
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 you do 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 a referral for a robotic radical prostatectomy to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the OON surgical services. You say that you believe that this Center of 
Excellence is necessary and recommended due to the need for more experience in providing this service. The 
Plan denied your request. The Plan says the recommendations for this to be done in a specific high-volume 
center are outdated as this type of surgery is now commonplace. The network has many providers with 
experience and qualifications to provide this surgery. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 OON surgical services. Our reviewer says that the documentation does 
not support that OON care is necessary for the requested procedure. Our physician reviewer found the enrollee 
is a male with prostate cancer for which radical prostatectomy is desired. Request is for coverage of 
laparoscopic radical prostatectomy to be performed in a Center of Excellence rather than with a qualified in-
network surgeon.  
 
The documentation supports that the Plan's network has experienced urological surgeons able to provide this 
procedure. The National Cancer Institute (NCI) does not state that patients have to find a Center of Excellence 
for prostatectomy. There is no peer-reviewed evidence to support that a Center for Excellence is able to provide 
better outcomes. The requested OON referral is 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 OON surgical services have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve the OON surgical services. Therefore, we decided that 
the Plan does not have to pre-approve a referral for a robotic radical prostatectomy to be provided by an out of 
network (OON) provider.
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 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." 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to further reimburse you for the contact lenses (V2520, V2521) 
purchased October 5, 2020. 
 
You asked the Plan to further reimburse you for the contact lenses. You say that you would like to be further 
reimbursed for the contact lenses. The Plan denied your request. The Plan says you have exhausted the benefit 
for $300 for contact lenses. 
 
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. The Plan covers these services with $300 benefit every 12 months for eyeglasses, frames, lenses or 
contact lenses. 
 
We looked at the file and the Plan's rules. The file indicates that you had previously used $250 of the benefit in 
December 2019. Therefore, you only had $50 remaining in the benefit until December 2020. Based on this 
information, we decided that the Plan's rules for coverage of the contact lenses have processed correctly. 
Therefore, we decided that the Plan does not have to further reimburse you for the contact lenses (V2520, 
V2521) purchased October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the ESI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has had a number of ESIs, and the level of relief is not clearly documented. 
It also appears that the enrollee has had the maximum number of injections for this six-month period. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs may be covered when reasonable and necessary. 
The maximum allowed per six-month period is three ESIs. 
 
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 ESI. Our reviewer says that the 
requested ESI is not covered according to the Medicare guidelines. Our physician reviewer found the enrollee 
has had three ESIs between October 2020 and January 2021. This request exceeds the frequency criteria of the 
LCD. The request is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PureWick female external catheter system. 
 
You asked the Plan to pre-approve the PureWick system. You say that you need this to help you with your 
incontinence. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that the DME MACs and the Pricing, Data Analysis, 
and Coding (PDAC) contractor are responsible for assigning individual DMEPOS products to HCPCS code 
categories for billing Medicare. For Medicare claim purposes, this product classification listing is accepted as 
evidence of correct coding.  
 
In this case, the PDAC has reviewed the requested item and assigned a code of A9270, which is "noncovered 
item/service." Since this item is correctly coded as a noncovered item, Medicare coverage is not allowed. 
Therefore, we decided that the Plan does not have to pre-approve a PureWick female external catheter system.