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

 
We decided that the Plan does not have to waive the coinsurance for the pertuzumab injection (J9306) and the 
trastuzumab-anns injection (Q5117) provided on April 3, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the services provided. 
 
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 20% 
coinsurance for each Medicare-covered Part B drug.  
 
You have been asked to pay a $1,550.88 coinsurance ($7,754.40 allowed amount x 20% coinsurance) for the 
Part B drugs administered. 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 coinsurance for the pertuzumab injection 
(J9306) and the trastuzumab-anns injection (Q5117) provided on April 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom-fabricated oral appliance for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says no evidence has been received showing that you cannot tolerate a CPAP. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not have obstructive sleep apnea, based on the sleep study performed in 2017. The 
overall AHI is normal at 2.5. A mandibular advancement device 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom-fabricated oral appliance for the enrollee.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a full 12 month prescription of alpha 1-proteinase inhibitor 
(J0256). 
 
You asked the Plan to pre-approve a full 12 month prescription of alpha 1-proteinase inhibitor (J0256). You 
say that a full 12 month prescription of alpha 1-proteinase inhibitor (J0256) is medically necessary. The Plan 
denied your request. The Plan says that a full 12 month prescription of alpha 1-proteinase inhibitor (J0256) is 
not medically necessary. 
 
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 a full 12-month prescription of alpha 1-
proteinase inhibitor (J0256). Our reviewer says that a full 12-month prescription of alpha 1-proteinase inhibitor 
(J0256) is medically necessary. Our physician reviewer found this enrollee has alpha-1 AT deficiency as well 
as severe persistent asthma, with severely impaired lung function.  She has been on replacement therapy for 
several years, and is known to tolerate the treatment with this medication.  Replacement therapy is reasonable 
and medically necessary for this enrollee.  This will be a lifelong treatment for her.  It is not reasonable to 
require re-certification of need in 6 months. A full 12 months of treatment should be approved and is medically 
reasonable and necessary for the enrollee in this case. 
 
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 full 12 month prescription of alpha 1-proteinase inhibitor (J0256) have been 
met. Therefore, we decided that the Plan has to pre-approve a full 12 month prescription of alpha 1-proteinase 
inhibitor (J0256).  
 
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 (K0554). 
 
You asked the Plan to pre-approve a Dexcom G6. 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 if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Dexcom G6. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee may have an endocrine condition (seen post gastric bypass) characterized by 
abnormal and exaggerated insulin secretion (or glp-1 secretion) that can cause severe low blood glucose levels. 
Hence, coverage of the CGM is warranted here since the low blood glucose levels are interfering with the 
enrollee's ability to function (sleep) and the alarm feature of the G6 would allow him some reassurance that he 
would be alerted if his blood glucose levels were dropping and hence he can fall asleep with less anxiety about 
possible severe low blood glucose levels. 
 
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 Dexcom G6 have been met. Therefore, we decided that the Plan has to pre-
approve a Dexcom G6 (K0554).  
 
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 genetic testing (G0483) provided to the enrollee on October 
29, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says there we no medical records provided to support the claim submitted. 
 
Medicare rules say that providers must produce medical records showing why the lab services provided were 
medically necessary. In this case, there were insufficient records provided to show the results of this testing 
would be used to determine a diagnosis or determine a treatment strategy for disease or illness present in the 
enrollee at the time of service. This testing is not covered for screening purposes. Medicare coverage criteria 
are not met.  Therefore, we decided that the Plan does not have to pay for genetic testing (G0483) provided to 
the enrollee on October 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative identification of sentinel lymph nodes (38900) 
provided on October 22, 2019. 
 
You asked the Plan to pay for intraoperative identification of sentinel lymph nodes. You say that this code is 
documented. The Plan denied your request. The Plan says there is a more appropriate code for the service 
performed. 
 
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 38900 is intraoperative identification (eg, mapping) of 
sentinel lymph node(s) includes injection of non-radioactive dye, when performed (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 intraoperative identification of sentinel 
lymph nodes. Our reviewer says that this code is not supported. Our physician reviewer found while the 
submitted medical records document an injection of a radioactive tracer, technetium-99, documentation of 
mapping of the sentinel lymph node was not included. Therefore, CPT 38900 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 intraoperative identification of sentinel lymph nodes have not been met. 
Therefore, we decided that the Plan does not have to pay for intraoperative identification of sentinel lymph 
nodes (38900) provided on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vaccines provided on July 5, 2019 under Medicare Part B. 
 
You asked the Plan to pay for vaccines under Medicare Part B. You say that these vaccines should be covered 
by the Plan. The Plan denied your request. The Plan says the vaccines provided are not covered under Medicare 
Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide vaccines under 
Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or 
directly exposed to any illness related to vaccines under Medicare Part B. Therefore, we decided that the Plan 
does not have to pay for vaccines provided on July 5, 2019 under Medicare Part B.  
 
Benefits for vaccines 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical removal of implant, tissue regeneration and 
bone graft, and surgical replacement of full sized implant. 
 
You asked the Plan to pre-approve surgical removal of implant, tissue regeneration and bone graft, and surgical 
replacement of full sized implant. 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. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical removal of implant, tissue regeneration and bone graft, and surgical replacement of full sized implant.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on July 
16, 2019. 
 
You asked the Plan to pay for the drug testing. You say that these services were medically necessary and 
should be covered. The Plan denied your request. The Plan says claims history shows no evidence of an 
established relationship or consultation with the ordering provider in this case. 
 
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 presumptive and 
definitive drug testing provided on July 16, 2019.
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 after spine surgery 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that a SNF will help the enrollee regain the muscle strength and mobility she had before her hospital admission. The Plan denied your request. The Plan says that the enrollee's continued needs can be met through a lower level of care.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper endoscopy. 
 
You asked the Plan to pre-approve an upper endoscopy. You say that the requested upper endoscopy is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested upper endoscopy. 
 
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 an upper endoscopy. Our reviewer says 
that the enrollee does not meet criteria for the requested upper endoscopy. Our physician reviewer found the 
enrollee is with chronic low back pain, diabetes, hyperlipidemia, tobacco smoking, "diabetic foot," status post 
lumbar fusion (10/4/2019), cholecystectomy, and tubal ligation. Pertinent to this review, charting from 
6/16/2020 documents that the enrollee has experienced transient diarrhea as well as 3 days of nausea (without 
vomiting) unresponsive to pantoprazole. Of note, the enrollee actively smokes marijuana supplemented with 
PRN Percocet.  
 
While persistent nausea qualifies as upper abdominal distress, available records do not support that the duration 
of pantoprazole use, nor that the following coverage criteria for upper endoscopy have been met in the 
enrollee's circumstance; Upper abdominal distress which persists despite an appropriate trial of therapy; Upper 
abdominal distress associated with symptoms and/or signs suggesting serious organic disease (e.g., prolonged 
anorexia and weight loss); Dysphagia or odynophagia; Esophageal reflux symptoms which are persistent or 
recurrent despite appropriate therapy; and Persistent vomiting of unknown cause. 
 
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 upper endoscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an upper endoscopy.
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 after seizures 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: 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 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 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. 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 health plan has approved ongoing care 
in the current acute care setting. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that intense physical therapy and occupational therapy 
are needed to maximize function and independence with mobility and activities of daily living. The Plan denied 
your request. The Plan says that the care is not complex enough and does not show it would cause excessive 
physical hardship for the patient to receive needed care in a skilled nursing facility. 
 
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. The 
patient is medically stable with Debility with no evidence of need for supervision by an acute physical 
medicine rehab physician or acute rehab nursing care. The patient may benefit from further physical therapy 
(PT) and occupational therapy (OT) but does not require an intensive therapy program. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
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 for the enrollee.