Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second unit of podiatry services (CPT 11042) provided to 
the enrollee on January 28, 2020. 
 
You asked the Plan to pay for the second unit. You say that this should be paid for. The Plan denied your 
request. The Plan says there is no documentation to support a second billing of CPT 11042. 
 
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 11042 is "Debridement, subcutaneous tissue; 20 sq cm or 
less." 
 
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 second unit. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
medical records do not support a second billing of CPT 11042 was appropriate. During this visit, it appears that 
the ulcerations were debrided, with the correct CPT code for ulcer debridement of ulceration being CPT code 
97597. In an appeal letter the biller for the podiatrist states that a molecular wound swab was performed. This 
does not meet the criteria for an excisional debridement such as code 11042. The progress notes state that the 
nonviable tissue and necrotic tissue were debrided from the ulcers, which is a billable code 97597. This was not 
appropriately billed. 
 
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 second unit have not been met. Therefore, we decided that the Plan does not 
have to pay for a second unit of podiatry services (CPT 11042) provided to the enrollee on January 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered from December 19, 2018 
to March 26, 2019. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy rendered from December 19, 2018 to March 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections (J2350, 96415, 96413) provided 
March 3, 2020. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you were told the injections would 
be covered in full. The Plan denied your request. The Plan says there is no record of a call in which you were 
told the injections would be fully covered. The correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Part B drugs.  
 
The enrollee has been asked to pay a 20% coinsurance for the injections. The injections fall within the Part B 
drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for injections (J2350, 
96415, 96413) provided March 3, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for an ultrasound (76705) provided on May 18, 2020. 
 
You asked the Plan to pay for an ultrasound. You say that the enrollee had multiple exams. The Plan denied 
your request. The Plan says that this code was not billed with modifiers to show it was a separate procedure 
from CPT 76700. 
 
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 Plan states that this was denied because CPT 76705 has a column 
one/column two relationship with 76700. However, the Plan has not submitted any documentation, such as a 
claim for or remittance advice, showing that 76700 was billed for this date of service. Therefore, we decided 
that the Plan has to pay for an ultrasound (76705) provided on May 18, 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Dexcom G6 Sensor. 
 
You asked the Plan to pre-approve the Dexcom G6 Sensor. You say that you would like reconsideration 
because this sensor is medically necessary. The Plan denied your request. The Plan says that this is not the 
preferred continuous glucose monitor with your Plan. 
 
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers, as long as specific conditions 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 Dexcom G6 Sensor. Our reviewer 
says that the member meets coverage criteria for the Dexcom G6 Sensor. Our physician reviewer found the 
member would benefit from a continuous glucose monitor with alerts. 
 
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 Dexcom G6 Sensor have been met. Therefore, we decided that the Plan has 
to pre-approve a Dexcom G6 Sensor.  
 
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 long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is not medically stable for transfer to an LTACH. 
 
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. Long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. The member is 
receiving acute hospital care, and acute care services have not been denied. There are no required medical 
services identified that are available at the LTACH, that are not available at the current health care setting 
being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy treatment. 
 
You asked the Plan to pre-approve the proton beam therapy treatment. You say that proton beam therapy is 
medically necessary and would offer the enrollee a better quality of life. The Plan denied your request. The 
Plan says proton beam 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 the proton beam therapy treatment. Our 
reviewer says that proton beam therapy is not considered medically reasonable and necessary in this case. Our 
physician reviewer found proton therapy for prostate cancer is not experimental, and in fact is an accepted 
treatment approach.  However, any potential benefit or detriment of proton therapy over standard intensity 
modulated radiation therapy (IMRT) for routine cases is an investigational. Our physician reviewer found that 
both ASTRO and the NCCN guidelines recommend against routine use of proton therapy. 
 
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 proton beam therapy treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve proton beam therapy treatment.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on August 30, 2020 with a moderately displaced left femoral neck fracture. The September 7, 2020 
therapy note states she is ambulating 15 feet with a two wheeled walker and minimal assistance. She needs 
contact guard assist with bed mobility and varied assistance with activities of daily living. The complexity of 
her medical, nursing, and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require an 
intensive therapy program 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay was medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 no required skilled nursing services are 
identified. The enrollee this requires skilled therapy services, i.e., are the specialized skill, knowledge and 
judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable 
treatment.  The documentation does not support that continued skilled therapy services on a daily basis in a 
skilled nursing facility. While the enrollee may benefit from continuing physical therapy (PT) and occupational 
therapy (OT), the records do not support the need for daily therapy. This patient does 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 continuation of SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the records do not show that LTACH care is 
medically necessary. The Plan says that they will continue to cover acute level of care at the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided requiring admission to a LTACH. The enrollee's 
status is improving. He is tolerating pressure support and is beginning trach collar trials. The enrollee is 
receiving medically necessary acute and/or critical care. The enrollee does not have clinical conditions that 
cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a 
therapeutic advantage. The review has determined that the enrollee does not require services at the LTACH that 
are not available at the acute care hospital where he is currently receiving care. There are no services available 
at the LTACH that the enrollee requires that are not available at the health care setting being offered by the 
health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound therapy services (CPT 97035). 
 
You asked the Plan to pre-approve the ultrasound therapy services. You say that your back really hurts and the 
requested services will help with your mobility. The Plan denied your request. The Plan says the code in 
dispute would not be included as covered chiropractic treatment. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that you are requesting ultrasound therapy to be performed by a chiropractor. The records 
show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does 
not have to pre-approve ultrasound therapy services (CPT 97035).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that the patient is recovering from COVID 19 
and is still in respiratory failure. The Plan denied your request. The Plan says that transfer to an LTACH would 
add no additional services. 
 
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. The enrollee 
is receiving appropriate care at the present acute care facility and when she is considered medically stable may 
be an appropriate candidate for care at a less intense level. There are no services available at the LTACH that 
the enrollee requires that are not available at the health care setting being offered by the health plan. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ferralet 90 for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under 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 Ferralet 90 for the enrollee.  
 
Benefits for this drug 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 LTACH services with an out-of-network provider. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says medical need is shown; however, the provider is not in-network with the 
Plan. 
 
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 Plan states the medical need is shown; however, the enrollee needs to use a network plan provider. The 
provider you are requesting is not in-network 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 LTACH 
services with an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission to a psychiatric hospital for 
electroconvulsive therapy. 
 
You asked the Plan to pre-approve an inpatient admission. The Plan denied your request. The Plan says the 
enrollee's severity of symptoms does not warrant a hospital admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient admission. Our physician 
reviewer found that the enrollee was offered two referrals during inpatient treatment for Electroconvulsive 
Therapy (ECT), which was declined. CMS guidelines suggest the procedure not to be a matter of convenience 
for inpatient Electroconvulsive Therapy as the enrollee is not a danger to himself or others. He does not require 
24-hour nursing, medical, or psychiatric care. Based on the information provided, inpatient treatment utilizing 
Electroconvulsive Therapy is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission to a psychiatric hospital for electroconvulsive therapy.