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

 
We decided that the Plan does not have to pay for the enteral formula and related accessories billed for services 
provided from April 10, 2020 to May 9, 2020. 
 
You asked the Plan to pay for the services provided. You say that the medical records do support the codes 
billed. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain valid proof of delivery for the supplies provided for the dates of service at issue in 
this case. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the enteral formula and related 
accessories billed for services provided from April 10, 2020 to May 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavioral health services provided from May 21, 2019, 
through August 2, 2019. 
 
You asked the Plan to pay for the behavioral health services. The Plan denied your request. The Plan says you 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for behavioral health services provided from May 21, 2019, through 
August 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Denosumab injection (J0897) received 
on June 12, 2020. 
 
You asked the Plan to waive the coinsurance for a Denosumab injection. You say that you don't think you've 
had to pay for this injection before. The Plan denied your request. The Plan says the correct coinsurance 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare-covered Part B prescription drugs.  
 
You have been asked to pay $232.08, or 20% coinsurance of the Plan-allowed charge of $1,160.40, for a 
Denosumab injection. A Denosumab injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for a Denosumab injection (J0897) received on 
June 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the abdomen (74170). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the 
requested CT imaging is not medically necessary. Our physician reviewer found there is no documentation 
provided supporting a follow-up CT of the abdomen for the 1.6cm adrenal nodule.  The requested CT Scan 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Computed Tomography (CT) of the abdomen (74170).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound copayment provided by a 
participating provider on June 10, 2020. 
 
You asked the Plan to waive the copayment for radiological diagnostic services. You say that you were told 
these copayments would be waived. The Plan denied your request. The Plan says the correct copayment has 
been applied. The Plan says that only certain services will have their copayments waived. 
 
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 $160 
copayment for outpatient diagnostic tests/radiological diagnostic services.  
 
You have been asked to pay $133.40 which is less than your copayment amount of $160 for radiological 
diagnostic services. Radiological diagnostic services fall within the outpatient diagnostic tests/radiological 
diagnostic 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 copayment for an ultrasound 
copayment provided by a participating provider on June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on February 18, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service February 18, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for Guardant360 testing provided on February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic screening testing provided on January 5, 2020. 
 
You asked the Plan to pay for genetic tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not support the Place of Service (POS) code billed on this claim or that these tests were ordered by the 
enrollee's treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. This claim was billed with Place of Service (POS) 81, indicating an 
independent laboratory setting, however the documentation does not support that the sample for this testing 
was taken in an independent laboratory setting. Based on this information, we decided that Medicare rules for 
coverage of genetic tests have not been met. Therefore, we decided that the Plan does not have to pay for 
genetic screening testing provided on January 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the epidural steroid injection you received 
on April 24, 2020, at an outpatient hospital facility. 
 
You asked the Plan to waive the copayment for the epidural steroid injection. You say that you were told that 
copayments were being waived. The Plan denied your request. The Plan says you were charged this amount 
correctly.  The Plan has only agreed to waive copayments for primary care, specialty care, and Physicians? 
Assistant/Nurse Practitioner services provided between May 11, 2020, and September 30, 2020.  The services 
you received were outside of this date range and are not the type of services for which a copayment waiver is 
available. 
 
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 $350 
copayment for surgery or other services provided at an outpatient hospital.  
 
You have been asked to pay a $350 copayment for the epidural steroid injection. The epidural steroid injection 
falls within the surgery (or other services) provided at an outpatient hospital 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 copayment for the epidural steroid injection you received on 
April 24, 2020, at an outpatient hospital facility.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of chronic obstructive pulmonary disease, hypertension and cardiomyopathy who presented to 
the acute hospital on 10/16/2020 with shortness of breath. She was treated in the hospital with supplemental 
oxygen, nebulizers, intravenous antibiotics and corticosteroids for a chronic obstructive pulmonary disease 
exacerbation. She is weak and deconditioned and is working with physical and occupational therapy. She is 
walking 20 feet with contact guard assistance and is contact guard assist for transfers and minimum assist for 
activities of daily living. Her therapy is reported to be limited by poor endurance and shortness of breath; 
physical therapy recommends transfer to a skilled nursing facility in the provided records. She is reported to be 
medically stable for discharge. 

Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern 
that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation facility. 
 
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee was admitted with diagnosed COVID-19 following recent Guillain-Barre syndrome while undergoing 
rehabilitation. She was ready to discharge home from rehab when she was tested positive for COVID-19 on 
10/8/2020, then was transferred to an isolation room followed by transfer to a COVID unit in a specialty 
hospital. Current vitals are stable and it has been more than two weeks since testing positive. No specific acute 
conditions require a prolonged hospitalization. 
 
The enrollee appears to be stable and clear for discharge very soon (less than 25 days). The enrollee does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, 
this request for LTACH 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjustable bed (E0297). 
 
You asked the Plan to pre-approve the bed. You say that the adjustable bed is medically necessary. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve an adjustable bed 
(E0297).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder, 
pelvis and lower extremities (72141, 73718, 72195, 73221). 
 
You asked the Plan to pre-approve the MRI's. You say that the MRI's are medically necessary. The Plan denied 
your request. The Plan says 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 the MRI's. Our reviewer says that the 
requested MRI's are not medically necessary. Our physician reviewer found there is no specific clinical 
rationale for the requested MRI studies. There are no plain films of the left shoulder or pelvis. 
 
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 MRI's have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder, pelvis and lower extremities (72141, 
73718, 72195, 73221).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick external catheter (A2970). 
 
You asked the Plan to pre-approve the Purewick external catheter. You say that the external catheter is 
medically necessary due to frequent infections. The Plan denied your request. The Plan says this is not a 
covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that for female external urinary collection devices, 
more than one meatal cup (A4327) per week or more than one pouch (A4328) per day will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The requested female external catheter system exceeds the one cup 
per week and one pouch per day that is covered. Based on this information, we decided that Medicare rules for 
coverage of the Purewick external catheter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Purewick external catheter (A2970).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve the seat lift mechanism. You say that a lift chair would be helpful in keeping 
the enrollee more independent and comfortable, as well as help reduce the risk of compression fractures and 
ease the work of her caregivers. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above 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 seat lift mechanism. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not 
reveal objective evidence that the enrollee has severe arthritis of the hip. The documentation does not reveal 
that the enrollee has a neuromuscular disease. The documentation indicates a certificate of medical necessity 
for a seat lift. The documentation does not support that a seat lift is likely to affect improvement in the 
enrollee's condition or arrest or retard deterioration in the enrollee's condition. The records do not indicate that 
the enrollee is completely incapable of standing from a chair in the home on a physical exam. The records 
indicate the enrollee has difficulty with ambulation. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no advantage in moving the enrollee from the current acute care 
hospital 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. Our 
physician reviewer found 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. In this case, ongoing care needs include intravenous antibiotics, surveillance laboratory studies, 
wound vacuum care, colostomy,  and therapy services. The documentation does not support that the enrollee in 
this case requires services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. 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. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ferumoxytol, 9 cycles every 56 days.  
 
You asked the Plan to pre-approve ferumoxytol. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says there is no medical need for the requested drug. The Plan also says that 
the requested drug 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 the ferumoxytol. Our reviewer says that 
the requested drug is not medically necessary. Our physician reviewer found ferumoxytol is FDA approved for 
the treatment of iron deficiency anemia. The reviewer found that the enrollee has required intermittent 
feruxmoxytol but none has been given since July. The reviewer found that the enrollee does not presently have 
any evidence of iron deficiency. Therefore, the reviewer found that pre-approval of feruxymoxytol would not 
be indicated. 
 
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 ferumoxytol have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ferumoxytol, 9 cycles every 56 days.