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

 
We decided that the Plan has to pay for drug testing services (HCPCS G0483) provided to the enrollee on 
October 8, 2019. 
 
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 that the documentation submitted did not include a valid physician order/lab requisition or 
medical records (signed by the ordering physician) stating exactly what tests are to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
In this case, the CPT Code Manual definition of HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) 
drug identification methods able to identify individual drugs and distinguish between structural isomers (but 
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any 
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods 
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all 
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or 
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations 
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 
or more drug class(es), including metabolite(s) if performed." 
 
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 services. Our reviewers says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found there is clear 
documentation by the provider acknowledging the codes and itemizing the tests that were requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
drug testing services (HCPCS G0483) provided to the enrollee on October 8, 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: Unfavorable

We decided that the Plan does not have to waive the cost share for physician visits provided during a skilled nursing stay from August 23, 2019 to September 4, 2019.
You asked the Plan to waive this cost share. You say that you were not seen by anyone when you were in the facility. The Plan denied your request. The Plan says the medical records submitted show you received these services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 to $20 copayment for physician or practitioner services. You have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for physician visits provided during a skilled nursing stay from August 23, 2019 to September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 27, 2019 to 
November 18, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services (90791, 90832 and 90837) provided on September 
27, 2019 through November 18, 2019.. You say that you would like reconsideration because you have made a 
good faith effort to get these claims paid and have changed your processes to prevent this issue from happening 
again. The Plan denied your request. The Plan says there was no valid referral for this service. 
 
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 has network providers 
available who can provide 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 the medical services provided on September 27, 
2019 to November 18, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services (CPT 88305) provided to the enrollee on March 9, 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 the global service for CPT 88305 was previously allowed on a different claim.
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 88305 is "Surgical pathology, gross and microscopic examination." We find that CPT code 88305 is not supported in the medical record. Specifically, this code was already billed as a global service, and cannot be billed again as the professional component. 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 surgical pathology services (CPT 88305) provided to the enrollee on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the chiropractic services rendered from
January 3, 2019 to November 10, 2019.
You asked the Plan to waive the copayments for these services. You say that you had no copayment under the
prior Medicare agreement. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copayment for per Medicare-covered chiropractic services.
Review of the file shows that you received chiropractic services for 17 dates of service from January 3, 2019 to
November 10, 2019. You have been asked to pay a $10 copayment per date of service for these services, for a
total of $1,700. These services fall within the per Medicare-covered chiropractic services benefit category. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayments for the chiropractic services rendered from January 3, 2019 to
November 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from February 22, 2020
to March 22, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the service
was not medically necessary. The Plan also says that the SNF continued stay was denied for skilled nursing
care because the enrollee required no nursing services which would be considered skilled services by Medicare.
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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from February 22, 2020 to March 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for an office visit with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says an in-network physician needs to be used.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral for an office visit with an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cinqair 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 the medical records show an eosinophil level of 100 cells/ul from 8/7/20. 
 
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 based on the medical 
records provided, there is no documentation that supports that the Cinqair is medically reasonable and 
necessary for the enrollee as her eosinophil count does not meet prior authorization criteria. There is no 
documentation that this drug would be 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Cinqair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with accessories. 
 
You asked the Plan to pre-approve Group 3 power wheelchair. You say that you need this to maintain function. 
The Plan denied your request. The Plan says the denial of authorization for this item is correct, because the 
records do not show that you meet the criteria to qualify for a Group 3 power wheelchair. 
 
The Plan follows Medicare rules. The rules state that a Group 3 power wheelchair is only covered if the 
enrollee meets the above basic criteria for a power mobility device, in addition to any criteria specific to the 
requested Group 3 power wheelchair. 
 
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 Group 3 power wheelchair. Our 
reviewer says that you do not meet the Medicare criteria for the requested Group 3 power wheelchair. Our 
physician reviewer found the documentation does not support that you have a mobility limitation that 
significantly impairs your ability to participate in one or more mobility-related activities of daily living such as 
toileting, feeding, dressing, grooming, and bating in customary locations in the home, that cannot be 
sufficiently and safely resolved by the use of an appropriately fitted cane or walker. 
 
 
We looked at this physician's review, the file, and Medicare rules. Because you do not meet the basic criteria 
for use of a power mobility device at this time, you also would not meet the criteria for a specific Group 3 
power wheelchair or the requested Group 3 power wheelchair accessories. Based on this information, we 
decided that Medicare rules for coverage of Group 3 power wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 3 power wheelchair with accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vision therapy. 
 
You asked the Plan to pre-approve vision therapy. You say that the requested vision therapy is medically 
necessary. The Plan denied your request. The Plan says the requested vision therapy is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve vision therapy. Our reviewer says that 
the requested vision therapy is not medically necessary. Our physician reviewer found the enrollee is with a 
history of a hemorrhagic cerebellar stroke in April, 2020, and a repeat stroke during surgical repair. The 
enrollee has Vertical strabismus of her left eye and Fusion with defective stereopsis, with limited left EOM 
function, and double vision with both eyes open which is affecting her ability to ambulate. The optometrist has 
proposed vision therapy sessions, working towards creating high-level thinking, visual attention, and changes 
in the visual system. 
 
Visual therapy has not been proven to be an effective therapy for patients with vertical strabismus and diplopia 
due to hemorrhagic cerebellar stroke. The request is 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 vision therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vision therapy.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the lumbar spine. Our 
reviewer says that the services are medically necessary. Our physician reviewer found your most recent lumbar 
MRI was September 15, 2016 and results are in the records. According to the submitted records you have 
completed a 6 week course of physical therapy (PT) and the MRI exam is done to plan for nerve root ablation 
which is obviously a surgical procedure. Since the plan indicates an approval has already been issued for MRI 
of the lumbar spine you qualify for the exam since the last lumbar MRI was September 15, 2016. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have been met. Therefore, we decided that the Plan 
has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).  
 
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: 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 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 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a need for 
physical and occupational therapy but there is no need for an intensive rehabilitation program. There is not a 
reasonable expectation that you 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: 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 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 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 you were medically stable with no evidence of need for supervision by a physical, 
medicine, and rehabilitation (PMR) Physician or needs acute rehab nursing care. You may benefit from further 
physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF 
admission is not medically necessary based on your current functional status and lack of medical complexity. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin (J9045), Pembrolizumab (J9271), and
Gemcitabine hydrochloride (J9201).
You asked the Plan to pre-approve Carboplatin, Pembrolizumab, and Gemcitabine hydrochloride. You say that
you would like these drugs approved so that the enrollee has a chance at remission. The Plan denied your
request. The Plan says the information does not support these drugs/regimens to treat the enrollee's specific
cancer - metastatic non-small cell lung cancer.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Carboplatin (J9045), Pembrolizumab
(J9271), and Gemcitabine hydrochloride (J9201). Our reviewer says that these drugs do not meet coverage
criteria Our physician reviewer found the combination of Carboplatin (J9045), Pembrolizumab (J9271), and
Gemcitabine hydrochloride (J9201) is not food and drug administration (FDA)-approved for the enrollee's
diagnosis. Our reviewer found that the major drug compendia and clinical research shows no evidence to
support this combination in enrollee's with non-small cell squamous cell carcinoma.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Carboplatin (J9045), Pembrolizumab (J9271), and Gemcitabine hydrochloride
(J9201) have not been met. Therefore, we decided that the Plan does not have to pre-approve Carboplatin
(J9045), Pembrolizumab (J9271), and Gemcitabine hydrochloride (J9201).