Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered on August 26, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 97110 is not supported. 
 
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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the record shows that the 
services were performed in the home setting and there is a more appropriate code for these services. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the physical therapy services rendered on August 26, 2021.
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 this is medically necessary. The Plan denied your 
request. The Plan says based on Medicare guidelines and the information they have about the enrollees 
condition; they don't meet the requirements and could receive care in another setting such as SNF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 
 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you have COPD, you cannot breathe, and 
you need a CPAP. You are currently hospitalized because of trouble breathing. The Plan denied your request. 
The Plan says claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described, 
are denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found This patient has obesity-
hypoventilation syndrome and OSA.  There is a diagnosis of asthma, but prior pulmonary function testing 
shows restrictive lung disease, without obstruction.  ABGs during acute illness in the recent past are consistent 
with acute on chronic hypercarbic respiratory failure, most likely due to OHS.  Medicare does not cover a 
home ventilator for the treatment of OHS, or when used as BiPAP.  CPAP or BiPAP is the appropriate 
treatment. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix. 
 
You asked the Plan to pre-approve Vectibix. 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 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 Vectibix. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition in the manner prescribed. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the manner 
prescribed in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. The 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vectibix have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vectibix.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 29, 
2022, to May 28, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services are coverable under the Medicare Act. The 
Plan denied your request. The Plan says the enrollee did not receive daily skilled care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pay for SNF care. Our reviewer says that the SNF 
care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician 
reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from April 29, 2022, to May 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve clinical crown lengthening represented by code D4249. 
 
You asked the Plan to pre-approve clinical crown lengthening services. You say that you have a lot of pain on 
both teeth that is causing you extreme discomfort, irritation and sensitivity. The Plan denied your request. The 
Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
clinical crown lengthening represented by code D4249.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The enrollee is 
undergoing a planned Right Total Knee Arthroplasty. She is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure is not listed on the Inpatient Only List. 
The procedure is currently approved as an ambulatory procedure. There is no documentation provided to 
support the expectation the enrollee will require a greater than 2 midnight stay. Our physician reviewer found 
that the enrollee's condition does not meet criteria for coverage of inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing (81455) billed for date of service April 10, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says that the date of service for a clinical laboratory 
test or the technical component of physician pathology service must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. The rules say that generally, laboratory services should be reported with 
the date of specimen collection as the date of service. However, there are three exceptions to this rule. The 
rules also say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the 
IRE information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not acknowledged that there are exceptions to this rule, 
nor have they provided any argument to show that they do not apply in this case. There is an exception which 
specifically applies to samples of live tissue taken for chemotherapy sensitivity testing which is not addressed 
by the Plan. When the criteria are met for the rule exception, the correct date of service is the date the testing 
was performed. Therefore, we decided that the Plan has to pay for laboratory testing (81455) billed for date of 
service April 10, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on December 
11, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that are on a fixed income and 
cannot afford this charge. The Plan denied your request. The Plan says this cost sharing was charged 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 $225 
copayment for Ambulance services. 
 
 
 
 
 
 
 
 You have been asked to pay a $225 copayment for ambulance transport. This item/service falls within the 
Ambulance 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 ambulance transport 
provided on December 11, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing (81455) billed for date of service April 6, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says that the date of service for a clinical laboratory 
test or the technical component of physician pathology service must be the date the specimen was collected. 
The record shows that the specimen was collected on March 29, 2022, rather than the billed date of service of 
April 6, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that although laboratory services should generally be 
reported with the date of specimen collection as the date of service, there are three exceptions to this rule. The 
rules also say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the 
IRE information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the test at issue was performed on a solid tumor sample. There are 
three exceptions to the rule cited by the Plan, including one focused on samples of live tissue taken for 
chemotherapy sensitivity testing, which likely applies in this case. However, the Plan has not acknowledged 
that there are exceptions to this rule, nor have they provided any argument to show that they do not apply in 
this case. When the criteria are met for the rule exception, the correct date of service is the date the testing was 
performed. Therefore, we decided that the Plan has to pay for laboratory testing (81455) billed for date of 
service April 6, 2022.  
 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the ultrasound provided on March 10, 2022. 
 
You asked the Plan to waive the deductible for the ultrasound. You say that you are on a fixed income and 
cannot afford the deductible. The Plan denied your request. The Plan says this cost sharing was charged 
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 $1,000 
deductible for other outpatient diagnostic tests - radiological diagnostic services, not including x-rays. 
 
 
 
 
 
 You have been asked to pay a $1,000 deductible for the ultrasound. This item/service falls within the other 
outpatient diagnostic tests - radiological diagnostic services, not including x-rays 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 deductible for the ultrasound provided on March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM) provided on April 8, 2022. 
 
You asked the Plan to pay for the supply allowance for therapeutic CGM. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the documentation submitted did not sufficiently 
support the billed supply code. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the documentation does not support the relationship between the 
enrollee and the ordering provider. 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 
supply allowance for therapeutic continuous glucose monitor (CGM) provided on April 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Acthar. 
 
You asked the Plan to pre-approve Acthar. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Acthar.  
 
 
 
 Benefits for Acthar 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for homemaker services provided from April 3, 2022, to 
April 9, 2022. 
 
You asked the Plan to pay for homemaker services. The Plan denied your request. The Plan says a corrected 
claim is needed for processing. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. The file shows that a corrected claim is required for processing. 
Therefore, we decided that the Plan does not have to pay for homemaker services provided from April 3, 2022, 
to April 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from May 4, 2022, to May 
11, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed with the correct type of bill code. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x 
TOB code. Therefore, we decided that the Plan does not have to pay for the home health services rendered 
from May 4, 2022, to May 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional skilled nursing visits (G0299). 
 
You asked the Plan to pre-approve the additional visits. You say that you disagree with the assessment. The 
enrollee continues to require assistance with ADL's ambulation, eating and medication administration. The Plan 
denied your request. The Plan says the records do not support the need for a skilled nurse to make more visits 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional visits. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that additional 
skilled nursing services are required. The provided records do not document any acute or unstable medical 
conditions or changes in medication or treatment which would necessitate any further skilled nursing visits 
beyond what have already been approved. The records document the enrollee/caregiver have been educated on 
her disease process, proper diet and medications. No medical notes from the enrollees treating physician are 
provided documenting an order or need for additional skilled nursing services. The records do not document 
the need for intravenous medications, new tube feeding or ostomy care or daily complex wound 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 the additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 2 additional skilled nursing visits (G0299).