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

We decided that the Plan does not have to pay for the ankle foot orthosis (L1971) and the foot, plastic, silicone 
or equal, heel stabilizer (L3170) provided on April 17, 2020. 
 
You asked the Plan to pay for the ankle foot orthosis and the foot, plastic, silicone or equal, heel stabilizer. You 
say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the 
record does not include an itemized shipping/billing invoice. 
 
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. Specifically, the date of service billed does not match the 
proof of delivery documentation. 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 ankle foot 
orthosis (L1971) and the foot, plastic, silicone or equal, heel stabilizer (L3170) provided on April 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy with patient for forty-five minutes 
(90834) provided on April 14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you provided medically necessary services in good 
faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services by an out-of-network provider. 
 
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 psychotherapy with patient for forty-five 
minutes (90834) provided on April 14, 2020 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 continuous glucose monitor supplies (K0553) provided 
March 16, 2020. 
 
You asked the Plan to pay for the continuous glucose monitor supplies. You say that the items were medically 
necessary. The Plan denied your request. The Plan says the items are not supported by the provided 
documentation. 
 
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. The delivery ticket provided was not itemized and did 
not provide any tracking or order number. 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 
continuous glucose monitor supplies (K0553) provided March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services you received on April 
16, 2020. 
 
You asked the Plan to waive the copayment for the urgent care services. You say that you went to this urgent 
care facility due to a wound on your thigh as well as to get tested for COVID-19.  You say that they didn't give 
you the COVID-19 test, so you shouldn't have to pay the copayment. The Plan denied your request. The Plan 
says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for urgent care services.  
 
You have been asked to pay a $30 copayment for the urgent care services. This copayment applies regardless 
of the extent of services you receive or if you are satisfied with the services you received. 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 urgent care services you received on April 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on February 11, 2020. 
 
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says the claim must 
be submitted to the vision insurer. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. These services are 
not covered by Medicare or the enrollee's Part B plan. Please note that the claim for services must by submitted 
to the vision insurer for coverage consideration. Therefore, we decided that the Plan does not have to pay for 
the vision services provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99213) 
provided on March 2, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient 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 established patient office or other outpatient 
visit (99213) provided on March 2, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lift chair received May 7, 2020. 
 
You asked the Plan to pay for the lift chair. You say that the chair is medically necessary. The Plan denied your 
request. The Plan says the chair is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for a lift chair received May 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that based upon hospital medical records inpatient skilled nursing care and 
rehabilitation services are 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary for you. The 
Plan denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. Our physician reviewer found that your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultraviolet light system provided on March 31, 2020. 
 
You asked the Plan to pay for ultraviolet light system. You say that you are appealing with records. The Plan 
denied your request. The Plan says the denial of payment for this item is correct, because this item was not 
provided for a covered diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that an ultraviolet light system is covered for selected 
patients with generalized intractable psoriasis.  
 
We looked at the file and Medicare rules. This item was not provided for a covered diagnosis. Based on this 
information, we decided that Medicare rules for coverage of ultraviolet light system have not been met. 
Therefore, we decided that the Plan does not have to pay for an ultraviolet light system provided on March 31, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neurological monitoring services provided on December 
3, 2019 billed with codes 95909-26, 95886-26-50, and 95937-26-59. 
 
You asked the Plan to pay for the neurological testing. You say that this testing was performed as billed. The 
Plan denied your request. The Plan says there is no evidence that the testing billed was 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. 
 
We asked our coding 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 neurological testing. Our reviewer says 
that the documentation does not support the billing of these codes. Our coding reviewer found the enrollee is a 
77-year-old male who received services on December 3, 2019 for Common Procedural Terminology (CPT) 
95886 - Needle electromyography, each extremity, with related paraspinal areas, when performed, done with 
nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by 
three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure), 
Common Procedural Terminology (CPT) 95909- Nerve conduction studies; 5-6 studies and Common 
Procedural Terminology (CPT) 95937 - Neuromuscular junction testing (repetitive stimulation, paired stimuli), 
each nerve, any 1 method.  
 
 
 
 
Documentation submitted was carefully reviewed for above Common Procedural Terminology Codes. The 
procedure report did not document CPT 95886, CPT 95909 and CPT 95937. These codes cannot be verified as 
performed. Procedures should be reported with the most comprehensive CPT code that describes the services 
performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the neurological testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the neurological monitoring services provided on December 3, 2019 billed with codes 
95909-26, 95886-26-50, and 95937-26-59.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot stay in the hospital, 
and a nursing home cannot meet his oxygen needs. The Plan denied your request. The Plan says transfer 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 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 already being 
provided at the current facility. Our reviewer found that there are no services at the LTACH that the enrollee 
requires that is not already available and covered at the current facility. Our physician reviewer also found that 
continued care at the current facility appears appropriate, and current clinical status does not appear complex 
enough to justify a LTACH transfer at this time. Transfer to a lower level of care may be considered soon, 
when appropriate. 
 
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extensive pharmacogenomic testing panel provided on 
March 10, 2020. 
 
You asked the Plan to pay for the testing panel. You say that this testing was necessary to evaluate potential 
medication response. The Plan denied your request. The Plan says there is no evidence that the ordering 
provider has been treating the enrollee for a specific medical condition for which this testing was ordered. 
 
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 and the plan indicates the claim history shows no established relationship. 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 extensive pharmacogenomic testing panel provided on 
March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DNA screening provided on January 12, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for DNA screening. You say that the procedure was not initiated in the office, it was 
Telemed. The Plan denied your request. The Plan says services must be rendered by an in-network provider. 
 
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 DNA screening provided on January 12, 2020 
by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluorodeoxyglucose (FDG) positrion emission 
tomography (PET) scan of the brain. 
 
You asked the Plan to pre-approve the FDG PET scan. You say that it is felt this is needed to evaluate her brain 
function. The Plan denied your request. The Plan says there is no differential diagnosis of AD vs FTD. As such, 
this PET scan is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that FDG PET imaging of the brain is covered for 
enrollees who meet criteria for both AD and FTD, and the imaging is needed to make a definitive diagnosis. 
 
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 FDG PET scan. Our reviewer says 
that the requested imaging is not shown to be medically reasonable and necessary based on Medicare rules. Our 
physician reviewer found in this case the records provided for review did not show that the member met 
diagnostic criteria for both AD and FTD. Rather, the records did not readily suggest the presence of either 
condition at this interval. Rather, her neuropsychological evaluation suggested that memory impairments may 
be due to depression, anxiety, and mood disorder. Medicare does not cover the use of a PET/CT scan (of the 
brain) in the evaluation of dementia except to differentiate between AD and FTD--which are not present in this 
case. As such the requested study would not meet criteria for coverage. 
 
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 FDG PET scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fluorodeoxyglucose (FDG) positrion emission tomography (PET) scan of the brain.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office outpatient visit (99214) provided on June 1, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for office outpatient visit. You say that you verified over the phone that the claims 
denied because an authorization was required and the plan would not allow a retro authorization. The Plan 
denied your request. The Plan says prior authorization is required for non-emergent services by an out-of-
network provider. 
 
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 outpatient visit (99214) provided on 
June 1, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the Keytruda. You say that the enrollee has very limited treatment options 
available due to her treatment history, as well as her current performance status. You say that the requested 
drug is a well-tolerated therapy that has shown activity in the treatment of cancers with high PDL1 expression, 
just as the enrollee's tumor expresses. The Plan denied your request. The Plan says the enrollee's condition does 
not meet the standards for coverage of the requested drug. 
 
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 the Keytruda. Our reviewer says that 
the criteria for coverage of Keytruda have not been met. Our physician reviewer found the requested drug is not 
FDA-approved for pancreatic cancer or based on PD-L1 status. The use of Keytruda without evidence of 
dMMR, MSI-high, or high mutational burden, is not supported by one of the major compendias or by clinical 
research that appears in a CMS-approved medical journal. 
 
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 Keytruda have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.