Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for milrinone lactate (J2260) provided on April 14, 2020 to April 
20, 2020. 
 
You asked the Plan to pay for milrinone lactate. You say that this was medically necessary. The Plan denied 
your request. The Plan says there is not a valid proof of delivery. 
 
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 a valid proof of delivery for the supplies provided in this case. The delivery ticket 
in the file does not include the carrier's tracking number, nor does the proof of delivery include an order 
number or details to corroborate the delivery ticket submitted. 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 milrinone lactate (J2260) provided on April 14, 2020 to April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 10, 2020, to January 30, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the facility 
or the provider; therefore, payment has been correctly denied. 
 
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 office visit provided on January 10, 2020, to 
January 30, 2020, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from the level of 
monitoring, responsiveness, and treatment that is provided at an inpatient rehabilitation level of care to prevent 
further complications and promote a safe discharge home. The Plan denied your request. The Plan says 
Medicare coverage criteria have not been met for admission to an acute IRF. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for 
physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy 
program. Our physician reviewer also found that there is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee is unable to find a clinical trial that she 
can go to safely. The Plan denied your request. The Plan says that the enrollee does not meet the standards for 
coverage. 
 
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 Keytruda. Our physician reviewer 
found that the requested use of Keytruda is FDA-approved for the enrollee's diagnosis. There is data in non-
small lung cancer for continuing therapy in those with progression in only 1-2 sites, such as this enrollee, when 
using radiation to treat sites of progression. The use is not listed as not indicated, not supported or not 
recommended in any of the compendia. The documentation does support that the requested drug is safe and 
effective, and otherwise reasonable and necessary for this 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
pembrolizumab (Keytruda).  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the assistant surgeon services provided to you on June 26, 2019. 
 
You asked the Plan to pay for the services. You say that you had no choice over the assistant surgeon services. 
The Plan denied your request. The Plan says that the services were not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the services by a contract provider. The file does not show that the Plan provided notice 
that the services would not be covered. You had a reasonable expectation that the services you were provided 
would be covered by the Plan. Under Medicare rules, this means the services is considered approved by the 
Plan. Therefore, we decided that the Plan has to pay for the assistant surgeon services provided to you on June 
26, 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 pay for the rehab therapies provided on December 2, 2019, to 
December 30, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the rehab therapies. You say that you were not aware prior authorization was 
required. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the 
provider; therefore, payment has been correctly denied. 
 
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 rehab therapies provided on December 2, 2019, to December 30, 2019 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 
80159, 80173, and 82542 provided on October 1, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159, 80173, and 82542 are not supported in the 
medical record. Specifically, the documentation submitted did not support that Carbamazepine, Levetiracetam, 
Topiramate, Digoxin, Clozapine, or Haloperidol testing were performed with blood sampling. Blood specimen 
collection is by venipuncture; however, the lab requisition states a urine specimen was collected. In this case, 
we have confirmed that code 82542 has a bundled relationship with codes 80307 and G0483 and cannot be 
paid as billed. This code cannot be paid as a separate line item.  
 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80157, 
80177, 80201, 80162, 80159, 80173, and 82542 provided on October 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial intraoral x-ray (D0220) and the additional intraoral 
x-ray (D0230) provided on June 17, 2020. 
 
You asked the Plan to pay for the dental services. You say that the x-rays were necessary. The Plan denied your 
request. The Plan says 1 intraoral x-ray is covered per calendar year. The Plan says the frequency limit has 
been exceeded. 
 
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 and intraoral x-rays are covered, the 
frequency limit of once per calendar year has been exceeded. The record shows that the Plan paid for an 
intraoral x-ray that you received on January 31, 2020. Therefore, we decided that the Plan does not have to pay 
for the initial intraoral x-ray (D0220) and the additional intraoral x-ray (D0230) provided on June 17, 2020.
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 clinical documentation provided 
supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of 
LTACH care have 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 was admitted for difficult speech and ambulation. Computed 
Tomography (CT) of the brain confirmed a stroke due to basilar artery stenosis. The enrollee had increased 
weakness of the left side after admission, was intubated and placed on ventilator for airway protection due to 
neurologic status deterioration. The enrollee had multiple acute strokes, basilar artery occlusion, persistent right 
hemiplegia, and encephalopathy. IV abxs for staphylococcus positive blood cultures was completed and 
tracheostomy/PEG placement was done on October 22, 2020. Currently the enrollee is tolerating a 40% T-piece 
and has a Foley PEG for feedings. The enrollee still requires acute hospital level of care services and is 
receiving appropriate care at the present acute care hospital. 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee 
from August 1, 2019, to August 19, 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 you were not an eligible provider at the time of service. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says 
that outpatient mental health care requires prior authorization. The records provided do not show the enrollee 
had prior authorization. Therefore, we decided that the Plan does not have to pay for outpatient mental health 
services provided to the enrollee from August 1, 2019, to August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure provided on June 1, 2020. 
 
You asked the Plan to pay for the preventive procedure. You say that you were not notified that this provider 
was no longer in-network with your plan. The Plan denied your request. The Plan says this service is not 
covered. 
 
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 pay for the 
preventive procedure provided on June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for custom fabricated oral appliance (E0486) provided July 8, 
2020. 
 
You asked the Plan to pay for custom fabricated oral appliance. You say that your office has previously 
complied with the request of re-billing with taxonomy codes on the claim for different patients and after 
complying with the request, the claim continues to deny. The Plan denied your request. The Plan says missing, 
incomplete or invalid rendering provider taxonomy. 
 
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, a taxonomy code is required in order for the claim to be considered. A corrected claim needs to be 
submitted. Providers who may need to submit a corrected claim must do so within 120 days of the original 
claim remittance advice. Based on this information, we decided that Medicare rules for coverage of custom 
fabricated oral appliance have not been met. Therefore, we decided that the Plan does not have to pay for 
custom fabricated oral appliance (E0486) provided July 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have used all 24 one-way trips allotted 
for the 2020 benefit year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the shoulder surgery to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve shoulder surgery. You say that you do not want to go back to your previous 
provider. The Plan denied your request. The Plan says services must be rendered in network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
the shoulder surgery to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the combination oral/nasal mask and related oral cushion 
(A7027, A7028) provided on January 29, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the combination oral/nasal mask and related oral cushion. You say that you 
would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 combination oral/nasal mask and related oral 
cushion (A7027, A7028) provided on January 29, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental core buildups. 
 
You asked the Plan to pre-approve core buildups. The Plan denied your request. The Plan says the services are 
not covered benefits. 
 
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. 
 
The file shows that a core build up for teeth #3, 13,15,18, 19, 30, and 31 were requested. Although the Plan 
offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental core buildups.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care services provided on July 17, 
2018. 
 
You asked the Plan to pay for the initial nursing facility care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee was enrolled in hospice for the 
date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
 
 
 
 
 
 
 
 
 
 
 
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the initial nursing facility care services provided on July 17, 
2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy visit provided on December 17, 
2019 billed with code 99601. 
 
You asked the Plan to pay for the home infusion visit. You say that this service should be covered. The Plan 
denied your request. The Plan says the code billed is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 99601 has a status indicator of "I" in the Physician Fee Schedule, meaning that it is invalid for 
Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the home 
infusion visit have not been met. Therefore, we decided that the Plan does not have to pay for the home 
infusion therapy visit provided on December 17, 2019 billed with code 99601.